Upheld, recommendations

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Victoria Hospital. Mrs A had been deemed appropriate for discharge home but Mrs C and her family were concerned that Mrs A had lost weight and that her pain was not under control at the date of discharge. Mrs A had to be readmitted to hospital the day after discharge and passed away a number of hours later.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that initially Mrs A had received an appropriate medical review which had determined that Mrs A would be fit for discharge. Mrs A had reported pain while in hospital and additional pain relief had been prescribed to supplement her usual pain relief which she received at home. However, between the period of making the decision that Mrs A was fit for discharge and the actual date of discharge, Mrs A required additional pain relief which had not been resolved at the point of discharge. We found that the staff involved should either have allowed Mrs A to remain in hospital until her pain issues had resolved or discharged her home with additional pain relief. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to ensure that Mrs A's pain relief was under control at time of discharge. 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 ensure that a patient's pain relief is under control or addressed at point of discharge from hospital

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 modified Brunelli procedure to his wrist (a surgical procedure that can be used to correct instability in the wrist). Mr C complained that the board failed to inform him of the risks of the anaesthetic, particularly of phrenic nerve palsy (loss of the ability to move the diaphragm and to feel the sensations of the chest and upper abdomen).

We took independent advice from a consultant anaesthetist. We found that there was a failure to discuss the common possibility of temporary phrenic nerve injury with Mr C and that Mr C was not provided with any written information about the procedure. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to discuss the possibility of temporary phrenic nerve injury with him and for failing to provide any written information in accordance with the Association of Anaesthetists of Great Britain and Ireland guidance (AAGBI). 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 undergoing this type of procedure should be informed of the common risks such as possible temporary phrenic nerve injury. Information leaflets should be provided as per guidance from the AAGBI.

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 she had been unreasonably billed for water she had not used. Ms C said that she had received an unexpectedly high bill, and that she had been charged for a visit by Scottish Water to verify if the water usage was due to a faulty water meter. Ms C said Clear Business Water (CBW) had failed to read her meter for a year and that they had not told her she would be charged for the visit by Scottish Water. Ms C said she accepted there had been a leak on her pipework, but said it had not been significant and, had she been aware of it sooner, that she could have reduced the amount that she owed.

We found CBW had acted unreasonably by failing to read Ms C's water meter, as required, every six months. We also found it was unreasonable not to have informed Ms C that she might have to pay a charge for the visit by Scottish Water and, therefore, we upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Credit Ms C's account for the cost of the visit from Scottish Water.
• Calculate Ms C's average water usage since the meter was replaced and refund any difference between this figure and the sum sought by CBW from her final meter reading.

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

• Evidence CBW now have a process in place to ensure meter reads are taken in line with their obligations as a licensed provider.
• Ensure staff are aware of the importance of timeous apologies where failings have been identified.

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 actions of his child's (Child A) school in relation to an incident that took place during a meeting. Mr C said that the council failed to act appropriately after the incident took place. The council stated that there was no agreement about what took place during the meeting.

We considered that it was clear that Mr C and the school had provided a different account of the incident. Therefore, we did not take a view on what exactly took place during the meeting. However, we did have concerns about the lack of recording and reporting that took place following the incident. We appreciate that there was an element of professional judgement involved in what incidents should be recorded, however, under the particular circumstances, we considered there to be a number of factors that suggested further recording and reporting of the incident was warranted. This included the fact that an animal was involved in the incident, that a risk assessment had previously been carried out and the circumstances matched some of the risks identified, and that there was a disagreement between the school and parent about what had taken place.

We concluded that it would have been appropriate for the school to have recorded the incident and an appropriate senior member of staff to consider what took place in line with the council's Electronic Incident Reporting Standard. Therefore, we did not consider the school to have taken appropriate actions after the incident and upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take appropriate action after the incident involving Child A. 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:

• School staff should reflect on what happened and consider their responsibilities in relation to incident recording and reporting.
• In schools where animals are present for educational purposes, staff should be aware of what to do if something goes wrong and what should be recorded and reported.

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 and Mrs C complained that the council failed to follow a reasonable process in deciding to alter the foster carer's mileage allowance. The decision to change the mileage rate was a discretionary decision which the council were entitled to take. However, where there is a complaint that the discretionary decision was made without following a reasonable process, our office are entitled to investigate.

The council did not provide evidence that they had followed a reasonable process when altering the mileage rate. As no evidence was provided to support the specific mileage rate identified, or evidence of research to support the council's view that the new rate covered fuel costs for foster carers prior to the decision being made, the complaint was upheld.

Recommendations

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

• The council should ensure that they provide a clear rationale to support changes which directly affect foster carers.
• Make clear guidance available to foster carers for what the different allowances cover.

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 way the partnership had handled his request to be assessed for suitability for a single cell in prison. Mr C had approached the prison health centre about this matter, and was told that this was an issue for the Scottish Prison Service (SPS). He complained to the partnership about the prison health centre's refusal to support his request for a single cell.

Mr C wrote a letter to the health care team, saying that SPS staff had explained to him it was up to the mental health team to indicate whether he should be assigned a single cell.

We made enquiries with both SPS and the partnership. SPS confirmed that they are responsible for carrying out cell sharing risk assessments. If a prisoner believes they should be allocated a single cell, then SPS would expect a recommendation from the health centre to support that requirement.

The partnership said that decisions on single cell allocation were a matter for the SPS. They said it was not the role of healthcare staff to carry out an assessment for allocation of a single cell. They said there were limited situations in which NHS staff might be involved in requesting such an allocation, and these did not apply to Mr C.

While we accepted that it was the overall responsibility of SPS to allocate single cells, on the basis of the evidence put forward by SPS and the information they shared in support of their position, we concluded that when a prisoner asks to be allocated a single cell on medical grounds, such a request should be appropriately considered by the prison healthcare team. It is for healthcare staff to assess whether a single cell is required on health grounds and to determine whether those grounds exist or not. Therefore, we found that the health centre's handling of Mr C's request was unreasonable and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his request for a single cell reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide an opinion to the SPS about Mr C's need or otherwise for a single cell on the basis of his medical circumstances, in order for the SPS to make a decision.

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

• Discuss the issue of prisoners requesting single cells on the basis of medical grounds with NHS and SPS staff at the monthly meeting to clarify the role of the NHS.

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 board failed to provide reasonable care and treatment for his foot, and that the board did not respond to his complaint appropriately.

Mr C underwent surgery to address a bunion (a type of bony lump that forms on the side of the foot) at St John's Hospital. Mr C experienced problems after his operation, and had further surgery on the same area approximately four years later. At this time, Mr C was noted to have septic arthritis (inflammation of a joint caused by a bacterial infection) and a procedure was performed to wash out the joint and remove infected tissue. Mr C's problems continued to persist, and he required further surgery the following year.

We took independent advice from a consultant podiatric surgeon (a clinician who diagnoses and treats abnormalities of the foot). We noted that Mr C had presented with a foot that was difficult to correct surgically. While there was a lack of correction after the initial surgery, we did not conclude that this was an unreasonable failing by the board. Mr C also had concerns about the second procedure. We concluded that this had been performed reasonably. However, we noted that Mr C's foot wound had been slow to heal following the procedure and he had received extensive antibiotic treatment. In these circumstances, a post-operative x-ray should have been performed to determine whether there was evidence of spreading infection. An x-ray was not performed and we concluded that this was unreasonable. On balance, we upheld this aspect of the complaint.

Finally, Mr C raised concerns about the board's handling of his complaint, stating he had anticipated a more compassionate response. We found that the board's complaint response acknowledged the problems Mr C experienced appropriately. We also noted the board had not complied with the timescale under their Complaints Handling Procedure. Therefore, we upheld this aspect of the complaint. We noted that the board had acknowledged this failing and we made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to perform an x-ray following the second surgical procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .

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

• Where a patient receives joint washout and debridement treatment, an x-ray should be considered to establish if the infection has spread.

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, a support and advocacy worker, raised a complaint on behalf of her client (Mr B) about the clinical and nursing care and treatment his late wife (Mrs A) received when she was admitted to University Hospital Monklands.

We took independent advice from a consultant physician and a nursing adviser. In relation to the clinical care and treatment given to Mrs A, we found that the physiotherapy support had been reasonable. We also found that the administration of medicines and the clinical input at the time of Mrs A's death had been reasonable. However, we found that she should have been referred to the diabetes in-patient team early in her admission to the hospital and, had this happened, it was likely that insulin would have been started which may have avoided the development of a necrotic heel. We also found that there should have been better control of Mrs A's blood sugar which might have reduced her propensity to infection. We noted that communication or documentation of communication with the family could have been better. 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 a number of failings. In particular, that Mrs A did not receive the required interventions to prevent pressure damage and that there had been a delay in obtaining equipment to help prevent pressure damage. We also found there had been confusion over the diagnosis of a sacral wound and that Mrs A's food, fluid and nutrition needs were not met. Furthermore, we found that there was a failure to refer Mrs A to podiatry (medical treatment of the feet and their ailments) and that there were omissions in patient-centred care planning and incomplete documentation. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B and his family 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:

• Ensure that there is appropriate and documented communication with patients and/or their families during a patient's stay in hospital.
• Where a diabetic patient has consistent elevation of blood sugars there should be a thorough evaluation of their diabetes medication and an early referral to the diabetes review team.
• Nursing staff should ensure Healthcare Improvement Scotland (HIS) standards for prevention and management of pressure ulcers is followed.
• When a patient with diabetes shows a decreased appetite, a patient-centred care plan should be developed in line with HIS Standards for Food, Fluid and Nutrition and HIS Standards for Care of Older People in Hospital.
• Accurate records should be maintained in line with the Nursing and Midwifery Council Code of record-keeping and the HIS Scottish Wound Assessment and Action Guide.

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 daughter (Miss A) about the care and treatment that Miss A received at the Royal Hospital for Sick Children (Yorkhill) for a cyst on her kidney. Mrs C said that there was no transition management to help Miss A prepare for moving from children to adult services; about the decision to move Miss A to adult services; that she was discharged from the board's care prior to being successfully treated for a cyst; and that there was a delay in Miss A receiving a second operation to remove the cyst as a result of the move to adult services.

We took independent advice from a paediatric and adolescent (branch of medicine dealing with children and their diseases) consultant. We found that it was reasonable for the board to have discharged and transitioned Miss A to adult services at the time that they did. However, we also found that there were failings in the care provided to Miss A, specifically that there was a failure to have a coordinated plan and process in place to support Miss A's transfer from paediatric to adult services which led to a delay in treatment of the cyst. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for failing to transition her appropriately from paediatric to adult services. 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:

• There should be guidance in place for staff which sets out a clear pathway for transition from paediatric to adult services, including the age range and the degree of flexibility possible.
• Patients transitioning between paediatric to adult services should have a coordinated plan in place and this should be documented.
• A process should be in place for the transition from paediatric to adult services for clinicians to use to guide transition management.

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

Summary

Mr C complained on behalf of his mother (Mrs A) that the board did not reasonably respond to his complaint or his request for compensation.

Mrs A's belongings went missing whilst she was in hospital and searches did not locate them. Mr C complained to the board about the loss of Mrs A's belongings. The board accepted that there had been unreasonable delays in responding to the complaint and apologised for this. After contact from our office, the board accepted that they should have made much more of an effort to explain the reasons for these delays and that there was a missed opportunity to confirm to Mr C how to make a request for compensation for missing items. Therefore, we upheld Mr C's complaint that the board had not responded reasonably to his complaints.

Mr C also submitted a request for compensation for the missing items. The board made Mr C an offer of a sum that they told him had been reached after making an appropriate reduction for wear and tear from his estimated valuation of the missing items. The board's internal communication indicated that the offer had been made as a good will gesture as they did not accept any responsibility for the loss of the items. We found that the board's communication with Mr C was confusing because it did not make clear that the offer was a good will gesture. Therefore, we upheld Mr C's complaint that the board had not responded reasonably to his request for compensation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for causing confusion when responding to his request for compensation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .

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.