Upheld, recommendations

Summary

Mrs C complained on behalf of her son (Mr A) about the care and treatment he received from a care home in the Stirling council area. Mrs C removed Mr A from the care home back to his family home. Mrs C had become increasingly concerned about Mr A's welfare in the care home and its suitability for a person with Mr A's particular needs. After Mr A returned to the family home, Mrs C complained about the care home to the Care Inspectorate who then investigated. When the council became aware of the Care Inspectorate report and findings they contacted Mrs C for more information. Subsequently the council initiated an Adult Support and Protection (ASP) Investigation using their authority under the Adult Support and Protection (Scotland) Act 2007. The council investigation reported several months later and concluded that there was no evidence that Mr A was at risk of harm. Mrs C was unhappy with the conclusions of the council's report and also the quality and scope of their investigation. Mrs C complained to the council but remained dissatisfied and brought her complaint to us.

We took independent advice from a social work adviser. We found that the terms of the Adult Support and Protection (Scotland) Act 2007 only apply where a person is at possible risk of harm. By the time the council became involved, Mr A was living back at home and there was no suggestion he was at risk of harm, and so they should not have conducted their investigation as they did. We also found that the investigation did not properly consider and test all the evidence available and did not use an appropriate standard of proof (looking for near certainty rather than a balanced decision). We also found that the investigation of Mrs C's complaint by the council had not properly considered all of her concerns. Therefore, we upheld the complaint.

We noted that the council had previously provided us with evidence of changes it had already made to its processes and training of staff. We made a number of further recommendations to help ensure staff have the appropriate skills and knowledge to conduct both adult protection and complaints investigations in the future.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the unreasonable reporting of the adult support and protection investigation, and acknowledge how difficult this experience has been for the family. The apology should meet the standard set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mrs C and her family for the failure to properly consider Mr A's current situation in deciding to undertake an ASP investigation; conduct an investigation in line with their own guidance and timescales; communicate with Mrs and Mr C in an open and transparent way at all times; apply the appropriate standard to the evidence considered; properly assess and interrogate some of the evidence; identify these failures during their own complaint investigation; properly conduct a complaints investigation. 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 similar cases, calling all parties involved together to discuss and plan the way forward should be considered.
• Staff should be aware of the principles of the Adult Support and Protection (Scotland) Act (2007).
• Staff should be aware of how best to assist an adult with complex needs to communicate their views and wishes and be aware of how to access assistance in doing this.
• Staff should be aware of the purpose of any investigation and the relevant standards that apply. Staff should be able to appropriatley obtain and evaluate the evidence and use this to give reasons for decisions reached. The Scottish Government has issued guidance to decision makers which will help support staff in decion-making. This can be found at http://www2.gov.scot/publications/2010/02/23134246/0

In relation to complaints handling, we recommended:

• Full information relating to social work matters under investigation should be supplied when requested by the SPSO.
• Staff should be aware of the scope of a complaints investigation and the relevant standards that apply. Staff should be able to appropriately obtain and evaluate the evidence obtained and use this to give reasons for decisions reached. SPSO have issued

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 increased number of waste and recycling bins which are being stored on the pavement of his street. He said that the council were failing to address the issue. He asked for the council to have a formal policy in place for bin removal and to explain why his request to access reports/correspondence relating to this issue was not upheld. The council said a new mixed recycling service meant that there are more bins on the street and residents have told them that they have nowhere to store them. The council said that there is no quick solution to this and that they would be happy to explore any suggested options.

We found that the council were unable to provide evidence that they had consulted with residents about the issue of bin storage. They were also unable to provide evidence that they had carried out any assessment of alternative bin provision, such as communal disposal options. We also found that the council had not carried out the actions that they had said it would in response to Mr C's complaint, such as identifying and removing unused bins from the street. The council had already taken steps to improve record-keeping and to ensure that contact with the public was properly recorded. The council's responses to Mr C and to this office could not be supported by evidence other than staff recollection. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failures in relation to record-keeping and providing evidence of their actions. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Make a new offer to engage with Mr C in order to identify solutions to the bins storage issue.

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

• The council should consult with residents and inform them of the results.
• The council should review the bins to identify and remove any that are unwanted or unused.

In relation to complaints handling, we recommended:

• The council need to ensure that complaint responses are based on contemporaneous written evidence, not only on unsupported staff recollections.

Summary

Mr C complained about the clinical and nursing care and treatment provided to his late wife (Mrs A) during her admission to Ninewells Hospital. Mrs A was admitted with a history of leg swelling and a failing liver.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and from a nurse. In relation to the clinical care and treatment given to Mrs A, we found that the majority of the clinical management of Mrs A had been reasonable. However, we found that Mrs A's infection could have been handled better and that antibiotic therapy should have been started earlier. Given the failings identified, we upheld this aspect of the complaint.

In relation to the nursing care and treatment given to Mrs A, we found that the care delivered, documented and communicated was lacking at times. Also the specialist knowledge of nurses managing a patient with decompensated liver disease was lacking and the interventions needed to ensure a clear treatment plan was in place. We upheld this aspect of Mr C's complaint. However, we noted that the board has accepted and apologised for the failings in communication.

Mr C also complained that the board had failed to record an incident on the ward, in a reasonable way. The board accepted that on this occasion the actions of the nursing team fell below the standard they aimed to provide and apologised to Mr C. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings this investigation has 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:

• Staff need to be aware of the policy around escalation of patients and the board needs an assurance mechanism in place to monitor if this is being followed.
• All staff in the ward should have access to education specific to the speciality and patient condition - including care planning, nutrition and managing encephalopathy.
• Gastroenterology staff should be aware of the indications of antibiotics in liver failure and the ‘liver bundle’ guidance in caring for patients with end stage liver disease.

Summary

Mr C complained about the care and treatment his relation (Ms A) received at Raigmore Hospital. Ms A suffered from MPO ANCA associated vasculitis (a rare autoimmune disease) and was admitted to hospital with symptoms of diarrhoea and vomiting, headaches and abdominal pain. Ms A experienced episodes of haemoptysis (coughing up blood) while in hospital and died later that day.

We took independent advice from an adviser in acute medicine. We found that, when Ms A was admitted to hospital, a consultant review indicated that a pulmonary haemorrhage (an acute bleeding from the lung, from the upper respiratory tract and the trachea, and the alveoli) was a potential concern along with two other possibilities. We considered it was reasonable at the outset that the board did not proceed to give Ms A a chest x-ray as gastroenteritis (inflammation of the stomach and intestines) was suspected and there was only one episode of haemoptysis. However, we found that there was an unreasonable delay in performing a chest x-ray on Ms A following a second episode of haemoptysis. There was, therefore, a delay in identifying a pulmonary haemorrhage. We noted a member of the nursing staff appeared to identify the possibility of a pulmonary haemorrhage, and whilst this was communicated to the doctor, it was not acted upon. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for an unreasonable delay in performing a chest x-ray on your Ms A following a second episode of haemoptysis and a delay in identifying a pulmonary haemorrhage, given a consultant review indicated a pulmonary haemorrhage was a potential concern. 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:

• Raise awareness and understanding of MPO ANCA associated vasculitis and pulmonary haemorrhage. Ensure all staff feel they can raise concerns with a senior member of staff if they consider their concerns are not being addressed. Ensure safety measures are in place to ensure less experienced staff are aware of potential symptoms/problems.

Summary

Mr C visited his dentist due to pain in one of his teeth and agreed to a proposed course of treatment with the dentist. Mr C believed this would be provided under the NHS. Mr C found the communication around the cost of the treatment confusing saying that the dentist had not properly explained the costs or what was required before the procedure, and Mr C was concerned that he was over-charged. Mr C also complained about the standard of treatment he received and that the dentist failed to handle his complaint reasonably.

We took independent advice from a dental adviser. We found that the dentist failed to communicate the treatment plan and options in a reasonable way and that Mr C was not in a position to give informed consent; the breakdown of treatment options (NHS and private/independent) were not in line with relevant regulations; unacceptable materials were used; the findings of x-rays were unreasonably reported on; there was an unreasonable standard of care especially periodontal (gum) care; there was an unreasonable standard of record-keeping; and there were discrepancies in what was charged. We also found that the dentist failed to deal with the complaint in line with the complaints handling procedure. We upheld all aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to communicate with him in a reasonable way about the proposed treatment and costs, failing to provide Mr C with a reasonable standard of treatment and failing to handle his complaint reasonably. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reimburse Mr C for the costs of the dental treatment he underwent. The payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• Ensure the dentist communicates with and obtains consent from patients in line with the relevant regulations and standards.
• Ensure all breakdown of treatment options are delivered in line with the relevant regulations.
• Ensure that only materials deemed acceptable under the regulations are used.
• Ensure x-rays are reported on in line with the relevant regulations.
• Ensure care is delivered to a reasonable standard.
• Ensure record-keeping is in line with the relevant standards and guidance.

In relation to complaints handling, we recommended:

• Ensure all complaints are dealt with in line with the complaints handling procedure.

Summary

Ms C complained that the board failed to provide a reasonable standard of care and treatment to her brother (Mr A) after he was referred by his GP for bowel problems. Mr A underwent a number of tests and was diagnosed with rectal cancer with liver metastases (tumours that have spread to the liver from other areas of the body).

We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) . We found that there were no unreasonable delays in progressing Mr A’s treatment. The actions of staff in relation to carrying out liver and pelvic MRI scans were also reasonable. However, it had not been reasonable to wait until after a multidisciplinary team meeting to confirm the diagnosis of cancer to Mr A. There also should have been more evidence of involvement from a colorectal cancer nurse specialist, and it should have been clear to Mr A who to contact for information and support.

In relation to a consultation that Ms C and Mr A attended about Mr A’s treatment, we found that there should not have been a formal discussion with Mr A and his family about treatment until the relevant investigations had been completed. When he was seen, this should have been by an oncologist and not a colorectal surgeon. In addition, at the meeting Mr A was told that a further test had been arranged the previous week, whereas this test was only requested on the day of the meeting. In view of these failings, we upheld Ms C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with reasonable care and treatment. The apology should meet the standardsset 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:

• There should be early contact with patients to discuss the diagnosis
• All patients, newly diagnosed or with a suspected diagnosis of colorectal cancer, should have access at diagnosis to a clinical nurse specialist for support, advice and information.
• The board should consider when to arrange the key out-patient appointment and who the primary clinician should be.

Summary

Ms C complained that the board failed to provide her with reasonable information about a fistulotomy (a surgical procedure to treat a fistula - a small tunnel that develops between the end of the bowel and the skin near the anus), the risks involved and the other options available, before carrying out the procedure. Ms C was left incontinent after the surgery.

We took independent advice from a consultant surgeon. We found that Ms C had not been seen prior to the fistulotomy to discuss the risks and incontinence was not documented on the consent form. We found that although it had been reasonable to offer the surgery to Ms C, she should have been seen in clinic to discuss the risks and benefits as well as the other options for surgery. We considered that Ms C had not been provided with reasonable information about the fistulotomy before the operation was carried out. We, therefore, upheld this aspect of the complaint.

Ms C also complained that the board’s response to her complaint was inaccurate. The board’s response to her complaint had stated that other surgical options had been discussed with her. There was no evidence in the documentation we received from the board that this had been discussed with Ms C. We found that if this had been discussed, it should have been documented. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide her with reasonable information about a fistulotomy, the risks involved, the other options available before carrying out the surgery and for providing an inaccurate response to her complaint. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• The board should ensure that patients being considered for a fistulotomy are given reasonable information about the risks and benefits and other options and that this is documented. Patients should also be given sufficient time before the operation to consider this information.

In relation to complaints handling, we recommended:

• Where appropriate, statements in complaint responses should be supported by evidence.

Summary

Miss C complained about the care and treatment which her late father (Mr A) received at Forth Valley Royal Hospital. Mr A, who had a number of pre-existing health conditions, had been admitted after a fall as his general health had deteriorated. He was in pain and died not long after the admission. The family felt that there had been a lack of investigations by staff into a diagnosis and that they failed to appropriately manage Mr A's pain control or provide him with a reasonable standard of nursing care.

We took independent advice from a consultant physician and from a senior nurse. We found that while Mr A received a reasonable level of overall care, the management of his pain could have been better in that the rationale behind the decisions to change/amend medication for pain relief were not clear. The level of communication between the staff and Mr A's family could also have been improved. We upheld this aspect of the complaint.

In regards to the nursing care, we found that, although there was evidence of good care at times, there was also a failure by nursing staff to fully record Mr A's pain score and other charts which would have evidenced whether appropriate care had been given. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings in managing Mr A’s pain control and in communication with the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Apologise to Miss C for the failure to record whether action was taken to address Mr A’s pain; nutrition and fluid balance needs. 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:

• Staff should be aware of the importance of appropriately managing a patient’s pain control and ensuring that appropriate communication is given to family members.
• Staff should ensure that when action is taken to address patient needs that the appropriate records are completed in line with record-keeping guidelines.

Summary

Mrs C complained about the care and treatment her father (Mr A) received at Forth Valley Royal Hospital. Mr A had been admitted with sudden onset severe jaw pain, which was radiating to his chest and arms. He subsequently developed abdominal pain and a number of tests were carried out, including an abdominal ultrasound. On the following day, Mr A had a CT angiogram (a specialised scan using x-rays to look at the heart) of his aorta (the largest and main artery in the body). This confirmed a large aortic dissection (a tear) requiring urgent surgical intervention. Mr A was transferred to another board for this surgery. After the surgery, it was discovered that Mr A had suffered a spinal stroke. This left him paralysed and entirely reliant on carers.

We took independent advice from a GP, a radiologist (a specialist in the analysis of images of the body) and from a consultant cardiothoracic surgeon (a medical doctor who specialises in surgical procedures of the heart, lungs, oesophagus, and other organs in the chest.) We found that the ultrasound result should have been flagged up as highly significant and with greater urgency. Where a potential life-threatening abnormality emerges on a diagnostic test, every effort should be made to convey this result immediately to the clinical team involved. The failure to do so, in Mr A’s case, led to a delay in definitive diagnosis and potential treatment of the aortic dissection. We, therefore, upheld this aspect of Mrs C’s complaint. However, we found that earlier identification of the dissection and more timely surgery would not have necessarily changed the outcome for Mr A.

Mrs C also complained that the board had failed to comply with the relevant record-keeping guidance, as they had been unable to find some of Mr A’s clinical records. We found that the board had failed to follow their ‘Transportation of health records policy’ and we also upheld this aspect of Mrs C’s complaint.

Finally, Mrs C complained about the board’s response to her complaint. We found that in their response to her initial complaint, the board had failed to identify the major failing in Mr A’s treatment, which was the delay in highlighting the abdominal aortic dissection flap observed in the ultrasound examination. We also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in reporting the ultrasound result to the clinical team involved, and for the failings in relation to their handling of Mrs C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

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

• All administrative, clerical and clinical staff who are involved in the transfer of medical records should follow the Board’s Transportation of Health Records Policy.

In relation to complaints handling, we recommended:

• The board should ensure that complaints are investigated appropriately and that, when requested, they provide further information about the action they have taken in response to any potential failings identified.

Summary

Mrs C complained about the care of her late father (Mr A) at University Hospital Ayr. Mr A underwent surgery to remove bowel cancer and required further surgery due to a complication. He remained unwell thereafter and, due to his poor nutrition and weight loss, a decision was made to start nasogastric (NG) tube feeding (where a tube is placed through the nose into the stomach). However, the NG tube was mistakenly inserted into Mr A’s lungs instead of his stomach and this was not recognised prior to commencement of NG feeding. This error caused a severe deterioration in Mr A’s condition and he died just over a week later. The board carried out a Significant Adverse Event Review (SAER) and the Crown Office and Procurator Fiscal Service (COPFS) also looked into the circumstances of the death. As Mrs C was unhappy with the outcome of the board’s SAER and response to her subsequent complaint, she contacted the SPSO.

We took independent advice from a consultant gastroenterologist (a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines)(a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines). We considered that the board’s SAER process was reasonable and recommended appropriate policy changes to prevent a similar future recurrence. It was identified that there were some departures from existing policy but these did not contribute to Mr A’s death. These included record-keeping deficiencies and a failure to take all advised steps to obtain an aspirate (where a small amount of stomach content is sucked through the tube and the acidity checked to confirm correct placement of the tube). As the tube was incorrectly placed in this case, the further advised steps would have been unsuccessful anyway and an x-ray would still have been required. The significant failing was a consultant surgeon’s incorrect interpretation of the x-ray and consequent failure to identify the misplacement of the NG tube. This misinterpretation occurred out-of-hours when the consultant was in theatre preparing for surgery. The new policy position is that NG feeding will not be commenced overnight, and will only commence after a consultant radiologist has reviewed the x-ray and confirmed the correct placement of the tube.

We raised concerns that the board issued an initial death certificate which failed to record that Mr A died of aspiration pneumonia due to a misplaced NG feeding tube, when this was quite clear. COPFS subsequently amended the cause of death to include ‘misplaced NG tube and NG feed’. We upheld this complaint. While we were satisfied that appropriate steps had been taken to address the significant failing which contributed to Mr A’s death, we made some recommendations for the board to take additional steps.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the failure to issue a death certificate accurately recording that he died of aspiration pneumonia due to a misplaced NG feeding tube. 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:

• The board should remind relevant medical staff that, when issuing a death certificate, careful consideration needs to be given to ensuring it accurately reflects the cause and circumstances of the death, regardless of how that might be viewed or interpreted.
• The board should inform the Ombudsman what steps were taken following the SAER, or what steps they intend to take now, to ensure future adherence to local policy regarding obtaining an aspirate and keeping records of the NG tube insertion process.