Upheld, recommendations

Summary

Mrs C, an advocate, made a complaint on behalf of her client (Ms B). Mrs C complained about the care and treatment provided to Ms B's late partner (Mr A). Mr A had attended Ayr University Hospital after rupturing his patella tendon. He underwent surgical repair of his ruptured patella tendon and was discharged home the following day. Over the next few weeks, there was delay and a lack of clarity over how Mr A was to access follow-up care and treatment. His GP informed him that they had not received a copy of the discharge letter in the post and Mr A did not know who was to arrange a follow-up appointment at his local orthopaedic (specialism in the treatment of disease and injury of the musculoskeletal system) department, which was located in a different NHS Board area from the hospital where he received surgery.

These matters were resolved after discussion with the orthopaedic consultant who treated Mr A. However, Mr A suddenly became very unwell some days after his surgery and died following a cardiac arrest. The cause of Mr A's death was later recorded as a pulmonary embolism (a condition when a blood clot breaks off and ends up blocking a blood vessel in a person's lungs), resulting from deep vein thrombosis (a condition that happens when a blood clot forms in a deep vein, usually in the leg) in his calf.

Mrs C complained that Mr A had not been prescribed with chemical thromboprophylaxis (drugs to prevent thrombosis) on discharge and that his discharge was not handled reasonably or appropriately. In particular, she complained that he was discharged without an appropriate post-operative medical review, and that there was a delay in the hospital issuing the discharge letter and arranging an appointment with Mr A's local orthopaedic department.

The board acknowledged that there was a failure to follow the instructions of the orthopaedic consultant who had operated on Mr A and outlined what steps they intended to take to prevent this happening again. However, they concluded that the choice to discharge Mr A without recommending or prescribing chemical thromboprophylaxis was acceptable.

We took independent advice from an orthopaedic consultant. We found that, given Mr A's individual circumstances, the relevant guidance supported chemical thromboprophylaxis being prescribed to him on discharge. Therefore, we upheld this aspect of the complaint. However, we agreed with the board's position that there was no strong evidence to suggest chemical thromboprophylaxis would have prevented Mr A's pulmonary embolism.

In respect of Mr A's discharge from hospital, we found that patients who live outwith the board area should be given two copies of their immediate discharge letter, one for their own records and one to pass onto their GP. The board were unable to say whether this happened in this case. We concluded that it was likely that the board's policy on providing immediate discharge letters to people who live outwith the area was not followed on this occasion.

The board were also unable to confirm whether Mr A was provided with instructions about how to arrange a follow-up appointment with his local orthopaedic department or whether this was to be arranged by the orthopaedic department. We noted that, once the orthopaedic consultant who carried out the surgery became aware of this uncertainty, they appear to have acted promptly to resolve this. However, we considered that the lack of clarity prior to this to be a failing on the part of the board.

We considered whether it was appropriate for Mr A to be discharged without a review by the orthopaedic consultant. We confirmed that it is normal practice for a patient to be reviewed by a health care professional prior to discharge, and that a nurse-led discharge is commonplace in Scotland. Therefore, we considered it reasonable for Mr A to be discharged without being reviewed by a consultant.

Overall, we concluded that Mr A's discharge from hospital was not carried out in a reasonable and appropriate manner. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for failing to provide Mr A with chemical thromboprophylaxis and discharge him reasonably and appropriately. 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 from outwith the health board area should be discharged in line with the existing policy and provided with two copies of their discharge letter. Patients should be made aware whether on-going appointments are to be arranged by the discharging department or by the patient and their GP.
• Staff should be aware of when it is appropriate to utilise chemical thromboprophylaxis after surgery 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

Miss C was referred by her GP to a health board in Scotland for gender reassignment. However, although she was assessed as being eligible and referred to the board's gender identity clinic, she is still waiting for some treatment including surgery. Miss C said that the delay in treatment has had an adverse effect on her mental health, which has been exacerbated by the failure to keep her informed about the delays in a reasonable way.

We considered the relevant Scottish Government protocol, which requires health boards to ensure their gender reassignment service is provided in an effective way and within a reasonable time. We also considered the evidence from Miss C's clinical records about her contact with the clinic. We found that the board do not yet have a functioning gender reassignment pathway. We recognised the continuing difficulties the board experienced in providing some aspects of their gender reassignment service and noted the steps they had taken to re-establish this and address the remaining gaps identified. Even so, the board are still not in a position to provide a full gender reassignment service, which has a far-reaching impact on transgender patients.

In relation to communication, we found that the standard of communication between staff and Miss C and her family was unreasonable and noted it was likely the impact of delays on transgender patients would be compounded by any communication failings. In addition to staff failing to respond at all to communication, there was a failure to be open and transparent about the difficulties the board had in providing a gender reassignment service. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings identified in this investigation and acknowledge the impact that this has had on her. 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:

• Carry out an equality impact assessment when all the relevant services are established and provide a copy to this office.
• Finalise an action/improvement plan of the board's activities underway to establish a functioning gender reassignment pathway and provide a copy to this office.
• Review the current arrangements for communication and implement any changes identified to ensure the board meets the requirements of the protocol and the needs of transgender patients.
• Review the psychological support offered to patients accessing the board's gender reassignment service to ensure it is adequate in light of the potential impact delays and gaps in the service will have on patients.

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 had a number of concerns about the way the university handled a disciplinary process and an appeal process.

Mr C was subject to an allegation that he had committed academic misconduct in relation to a coursework submission. Mr C was invited to attend a disciplinary meeting to discuss the allegation. Mr C wished to bring his mother to the meeting; however, the university informed him that he could not do this under their policy. Following the conclusion of the meeting, Mr C was found guilty of collusion and a penalty was applied.

Mr C appealed the outcome of the appeal process. An informal meeting was arranged, to which Mr C brought his mother and university staff for support. No procedural failing was identified during the appeals process and Mr C was informed that grounds did not exist for the appeal to be considered.

We found that the university failed to consider making a reasonable adjustment in relation to the policy for who may accompany a student to a disciplinary meeting. We also found that the university failed to document their consideration of part of Mr C's appeal and provide him with a reason for their decision on this point. On balance, we upheld Mr C's complaints about the disciplinary and appeal processes.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to consider making a reasonable adjustment in relation to the policy for who may accompany a student to a disciplinary meeting; and failing to document their consideration of part of his appeal and provide him with a reason for their decision on this point. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .
• Provide Mr C with a reason for their decision on his appeal submission that his actions did not amount to collusion. If the university is unable to establish that this point was considered fully, then consideration should be given to re-opening the appeal for further consideration.

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

• Where appropriate, the university should consider making reasonable adjustments to ensure that disabled students can fully participate in education and enjoy other benefits, facilities and services that are provided to students.

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 Water Industry Commission for Scotland (WICS) failed to take reasonable or appropriate action in respect of the concerns he raised about a water provider.

We found that WICS did not handle Mr C's concerns in line with their Policy for Licence Contraventions. We considered that Mr C had attempted to raise a concern about a potential breach of licence conditions but WICS did not handle his correspondence in line with the relevant policies and procedures. We noted it was very difficult to find information about how to raise a complaint about a potential licence breach on the WICS website. As such, it would have been reasonable to expect WICS to provide Mr C with more information about their statutory role and details of the process for raising a complaint about an alleged breach of licence.

We concluded that it was unreasonable for WICS not to have accepted Mr C's original correspondence about an alleged licence breach or to have provided him with information about how to make such a complaint. Therefore, we upheld this complaint. In addition to this, we identified failings in how WICS handled Mr C's complaint about their service and provided feedback about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified as part of our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .
• If Mr C wishes to make a complaint about a potential license breach, WICS should accept this and consider it in line with their Policy for Licence Contraventions. If Mr C is not at the stage to make such a complaint, WICS should provide him with appropriate advice.

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

• Complaints about potential license breaches should be handled and considered in line with the Policy for License Contraventions and WICS' statutory requirements.
• Details about how someone can make a complaint about a potential license breach and what the role of WICS is in this regard should be clearly accessible on the WICS website.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the procedure detailed on the WICS website and on www.spso.org.uk/how-to-handle-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

Mr C raised a complaint with the Scottish Prison Service (SPS) because he was concerned that intelligence disclosed to him linked him to what he described as innocuous activity and groundless concerns. He also considered that a series of emails sent between SPS staff indicated a degree of misrepresentation of the factual situation and misrepresented the views of a member of staff from the psychology department. Mr C was unhappy with the way that the prison had handled his complaint. In particular, he had concerns about the time taken to respond to him and the steps taken to keep him informed of when he could expect to receive a full response. Mr C also had concerns about the quality of the response issued to him.

We found that the prison did not deal with Mr C's complaint in line with the timescale set out in prison rules. However, it is reasonable that not all investigations will be able to meet that timescale; some investigations are complex and require careful consideration and detailed investigation beyond the seven-day timescale. Where there are clear and justifiable reasons for extending the timescale, the SPS guidance on complaints confirms that a governor can inform the prisoner that there will be a delay and confirm when the response will likely be given.

In Mr C's case, the prison explained that the reason for the delay in issuing a response to his complaint was because a relevant member of staff was on leave, but they did not communicate a new timescale to him. We also found that the prison failed to address the fact that a staff member had in fact miscommunicated the views of another member of staff. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to fully address the concerns raised. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .
• Fully address Mr's C's concerns about the misrepresented views of the psychology department and the failure of senior staff to clarify the matter.

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 provided to him by the hospital when he had been admitted for a biopsy (a tissue sample taken for testing) and insertion of chest drain (a flexible plastic tube is inserted through the chest wall and into the affected area to drain it of fluid). He complained that pain relief had been inappropriate and caused urinary blockage; that there had been a failure to make a referral to his local hospital for urinary issues; and that his relatives had been informed there was a crash in his blood pressure, but that this was then denied.

We took independent advice from a surgeon. We found that the referral to Mr C's local urinary team was made appropriately and there was no evidence that Mr C had a blood pressure crash. However, we found that there were failures in Mr C's care and treatment in relation to the management of his pain; his pain was not assessed regularly and in line with the pain assessment chart, and the pain relief that was given was not adequate for Mr C's needs and was not in line with the British National Formulary on prescribing. We also found that management and monitoring of Mr C's urinary output and retention was unreasonable. We therefore upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failures in relation to the management of his pain, and management and monitoring of his urinary output and urinary retention. 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:

• Medication given for pain relief should be adequate for the patient's needs and in line with the British National Formulary on prescribing.
• Pain levels should be assessed in line with the general pain assessment chart.
• Urinary output should be monitored closely after surgery and staff should be alert to the possibility of urinary retention.

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 on behalf of her late uncle (Mr A) about the care and treatment he received from his GP practice. Ms C complained that the practice failed to treat Mr A as an urgent patient, even though he was experiencing symptoms that could have been caused by a stroke.

We took independent medical advice from a GP. We found that when Mr A contacted the practice, he did not provide information that suggested it was an emergency and it was reasonable that the GP arranged to see him later that week. However, the next day, Mr A's wife (Ms B) contacted the practice with concerns about Mr A's condition worsening and she spoke to another GP. Ms B asked for Mr A to be seen earlier but this was refused. We found that during this phone call, the GP failed to carry out an appropriate assessment of Mr A's condition, did not communicate reasonably, and inappropriately failed to see Mr A urgently, even though the symptoms Ms B described could have been caused by a stroke. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the failings identified in the care and treatment he received. 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:

• When a patient (or their representative) contacts a GP with concerns, the GP should take an adequate medical history and carry out an appropriate assessment of the patient's condition, in a manner that is in line with the General Medical Council guidance on good medical practice.

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

Miss C complained about the care and treatment she received from Ninewells Hospital in relation to the birth of her child. Miss C highlighted that her child has brain related problems. Miss C also complained about the time it took for the board to respond to her complaint.

Following the birth of Miss C's child, the board conducted a Local Adverse Event Review (LAER) to detail the root causes and key learning from an adverse event. The LAER found that the root cause was that Miss C had hyponatremia (low sodium concentration in the blood - a rare complication in low-risk labouring women). The LAER identified a number of concerns in terms of the administration of intravenous (IV) fluids on the midwifery unit, timing of blood tests, confusion surrounding the need to transfer Miss C due to her behaviours and significantly altered conscious state, and the obstetric (pregnancy and childbirth) team not being informed of the transfer and associated concerns. As a result, the board took action to address these issues to ensure learning and improvements.

We took independent advice from a consultant obstetrician and a midwife. We noted that Miss C was a low-risk patient at the beginning of her labour in the midwifery unit. We found that the progress of the first stage of Miss C's labour was unreasonable and she was given excessive fluids orally and by IV infusion which was not recorded on a fluid balance chart or reviewed by medical staff prior to IV fluids being given, after which she became unresponsive.

We also found that, despite not having any sedating analgesia (pain relief), the deterioration in Miss C's condition was not recognised and assistance was not requested. There was an unreasonable delay in transferring her to the labour ward, with unfamiliar staff being involved in the transfer and key information not communicated effectively to the new team. However, we were unable to say what effect earlier detection and treatment would have had on the outcome for her child.

After Miss C's transfer to the labour ward, the medical staff recognised her poor condition promptly and delivered her child. Had Miss C been transferred when the delay in the first stage of labour was diagnosed, it was likely that blood tests would have been taken leading to an earlier diagnosis of the problem. We found that there was a delay in obtaining and acting on the blood results which we considered unreasonable, although this delay would not have affected Miss C's child's outcome. In view of these findings, we upheld this aspect of the complaint. The board has already taken some action in respect of their findings on this case. However, we made further recommendations to ensure learning.

In terms of the board's handling of Miss C's complaint, we found that there was evidence that the complaints department made attempts to arrange a meeting to discuss Miss C's concerns with her and provide the complaint response within good time. However, it appears that there was a delay in clinical staff responding to these attempts. While the update response sent to Miss C was factually correct, in the absence of any evidence from the board justifying the delay, we found that the time taken to deal with the complaint was unreasonable. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to recognise her deterioration and for the delay in dealing with her complaint. 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 relevant staff should be fully appraised and aware of key information.
• All relevant staff should be able to recognise and manage a deteriorating patient.
• Clinical staff should respond to the board's complaint investigations in a timely manner.
• Patients should be appropriately transferred to obstetric care.
• Communication of blood test results should be recorded in a structured and consistent way.
• All staff taking blood tests should take responsibility to obtain the results or communicate with the next shift about any outstanding results.

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 that a dentist had failed to provide reasonable care and treatment to her. She said that the dentist inappropriately removed an inlay despite the fact that this had not caused her any problems.

We took independent advice from a dental adviser. We found that it had been reasonable for the dentist to remove the inlay, as there was evidence of decay, and to carry out drilling on the tooth to do so. We also found that it was reasonable for the dentist to refer Ms C to a specialist for root canal treatment. There were no failings by the dentist that led Ms C to develop an infection. The presence of decay meant that there was a risk of infection for Ms C, with or without treatment, and this risk would increase through time, given that the decay would most likely spread further. However, we found that there was insufficient evidence that the dentist gave Ms C adequate information about the likelihood of infection. Therefore, we upheld the complaint for this specific reason.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for this failing. 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:

• Dentists should ensure that, where appropriate, patients are given adequate information about the likelihood of infection and that this is 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 on behalf of his wife (Mrs A) about the care and treatment she received at Western General Hospital. Mrs A was admitted to the surgical assessment unit in the evening with a serious bowel condition. She experienced severe pain in the overnight period whilst she waited to receive surgery. The following morning surgery was successfully performed. Mrs A remained critically unwell for a number of weeks following the procedure.

In response to Mr C's complaint, the board acknowledged that better care could have been provided overnight and the operation should have been performed sooner. Mr C remained concerned about what happened and brought his complaint to us.

We took independent advice from a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques) and a registered nurse. We identified a number of issues with the care and treatment provided to Mrs A in the overnight period. In particular, we found that the CT scan performed was not reported accurately as it failed to mention the radiological evidence of mesenteric ischemia (a serious condition involving sudden interruption of the blood supply to a segment of the small intestine). We also found that the medical review and nursing monitoring in the period under consideration were unreasonable, and we noted issues with record-keeping.

We also found that nursing and medical staff had failed to escalate matters to senior medical staff when this would have been appropriate. Finally, and in line with the board's findings, we found that there was an unreasonable delay in transferring Mrs A to theatre for emergency surgery. We considered that earlier surgery would not have impacted on the extent of surgery required, but might have mitigated the severity of Mrs A's critical illness. We upheld Mr C's complaint and made a number of recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A and her family for the failings in CT reporting; failings in medical review; failings in nursing record-keeping; and failure to escalate the deterioration. 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:

• CT imaging should be accurately reported. Arrangements for supervision of on-call radiology registrars should conform to Royal College of Radiologists guidelines. The service should be satisfied that they have minimised the contribution of any systems deficiencies to radiological error.
• Nursing records should be maintained in line with the standards required by the Nursing and Midwifery Council Code.
• Nursing staff should have appropriate expertise and confidence in identifying deteriorating patients and escalating concerns to medical staff.
• Surgical staff should be alert to a patient's clinical condition and respond promptly to contact from medical colleagues.
• Where there is a risk that patient safety may be compromised, prompt action should be taken to escalate the matter to appropriate senior staff.
• The board should have an appropriate pathway in place for emergency laparotomy care.

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