Upheld, recommendations

Summary

Mrs C complained about the care and treatment her husband (Mr A) received at Inverclyde Royal Hospital and Royal Alexandra Hospital. Mr A was admitted with suspected empyema (pockets of infected fluid in the chest) and sepsis (a severe complication of infection). However, he was later found to have widespread cancer. After his discharge home, Mr A's condition worsened very quickly and he died the following week.

Mrs C complained that the board failed to provide Mr A with reasonable clinical care and treatment for his infection and/or sepsis. We took independent advice from a consultant respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs). We found that as Mr A was suspected to have empyema, there was a significant delay in carrying out his pleural tap (where a small needle or thin tube is used to remove excess fluid from around the lungs). This delay had been identified and acknowledged by the board. We upheld this aspect of Mrs C's complaint and made further recommendations in relation to this.

Mrs C also complained that the board failed to provide Mr A with reasonable nursing care in relation to pain management and nutrition. We took independent nursing advice. We did not find evidence of failings in how Mr A's pain was managed. However, we found that there was an unreasonable delay in carrying out Mr A's nutritional assessment and failings in how his fluid balance was recorded. We upheld this aspect of Mrs C's complaint.

Mrs C raised concerns about the board's communication with Mr A's family, in particular about his diagnosis of cancer. As the board acknowledged inadequacies in how the diagnosis was communicated, we upheld this aspect of the complaint. However, we found that the board had already taken appropriate action to address this and made no further recommendations.

Mrs C also complained that the board unreasonably discharged Mr A home and without a suitable care package in place. We found it was reasonable Mr A was discharged home. However, we found that the board should have offered Mr A support at home given his diagnosis of widespread cancer. Therefore, we upheld this aspect of the complaint. We found that the board had appropriately apologised to Mrs C for this but we made a recommendation for further action.

Mrs C also raised concern that the board failed to send Mr A's medical records to another health board. The board accepted the medical records should have been sent and we upheld this aspect of the complaint. We found that the board had taken action to address this and made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in aspects of Mr A's nursing care. 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:

• Patients suspected to have an empyema should receive timely pleural fluid sampling to clarify their diagnosis.
• Fluid balance charts should be completed fully for all patients, including those who are independent, or the reason why it is considered unnecessary should be clearly recorded.
• Patients diagnosed with cancer should be offered support from a specialist cancer nurse and/or community services.
• When a patient is discharged with cancer that cannot be treated, their GP should be informed so they can provide and/or arrange appropriate support.
• Patients should have a MUST (Malnutrition Screening Tool) assessment within 24 hours of their admission to hospital.

Summary

Mrs C complained about the care and treatment which her late brother (Mr A) received at Aberdeen Royal Infirmary. Mr A died suddenly at home, two days after being discharged from hospital. The cause of death was recorded as colonic impaction (hard stool in the colon) and renal failure (kidney failure). Mr A had been admitted to hospital as an emergency with colonic impaction and problems with urination. A manual evacuation of the bowel was carried out under anaesthetic along with trials of catheterisation (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Mr A was discharged with a catheter in situation and arrangements made for a urology review as an out-patient. Mrs C believed that Mr A had received inadequate care in hospital.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that while in hospital Mr A did undergo a number of appropriate investigations such as blood tests; radiographs of the abdomen and chest; bladder scan; suppositories; manual evacuation of the bowel under anaesthetic; and catheterisation. However, on the day of discharge there were signs that Mr A was still unable to manage a normal bowel motion and his urine output was low compared to his normal urine output levels. We found that staff should have arranged a urology review in hospital prior to discharge rather than refer for an out-patient appointment in due course. We also found that arrangements should have been made for urgent review of Mr A's inability to manage a normal bowel motion in the days after discharge from hospital. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to establish the reasons for Mr A's urine retention and to ensure that he had normal bowel movement prior to discharge. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should ensure that, where appropriate, an assessment has been carried out into the patient's ability to pass urine and maintain normal bowel motion prior to discharge.

Summary

Mrs C complained about the nursing care and treatment given to her late husband (Mr A) at Dumfries and Galloway Royal Infirmary. She also complained that communication by the board was poor.

Mr A had a complicated medical history. As he began to experience an increase in symptoms, he was admitted to hospital. Mrs C said that when she visited she found him in an undignified state. Later, she found that he had six stitches to a head wound, about which she had not been informed.

We took independent advice from a registered nurse. We found that the assessment taken on Mr A's admission noted that he could not properly answer questions to elicit information about his mental state, and that despite this, no further enquiries were made into whether or not he could be experiencing delirium, as was required. Similarly, despite his low score about his mental state, which should also have triggered a falls prevention plan and care plan, this did not happen. Mr A went on to fall twice, the second fall required him to have stitches. Furthermore although Mr A also appeared to be suffering delirium, the prescribed care for this was not evidenced in the nursing records and there were gaps in his care. We also found little record of conversations with Mrs C and she had not been told about his head wound until she visited him.

Given these failures, we upheld both aspects of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the identified failures in Mr A's care and treatment.
• Apologise to Mrs C for failing to communicate in a reasonable and appropriate way. 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:

• Patients admitted to hospital should have falls risk assessments carried out in line with the Board's Falls Management Policy and assessments identified following review, carried out promptly. Nursing care provided to patients should be in line with the Nursing and Midwifery Code, particularly in relation to the importance of good record-keeping. Patients should receive medication as prescribed and this should be documented appropriately.
• Family members and carers, as appropriate, should be kept up-to-date about a patient's treatment and condition. Where specific and reasonable requests for meetings/discussions have been made, these should take place and be recorded.

Summary

Ms C complained about the care and treatment her husband (Mr A) received from the board at University Hospital Crosshouse. Ms C complained that there was a delay in diagnosing and treating Mr A's squamous cell carcinoma (a type of cancer of the skin's cells). Mr A had been under the care of the board, as he had a suspicious area of damage on his tongue. Mr A was later diagnosed with cancer in his tongue, which had spread to his neck. Mr A's cancer appeared to have been successfully treated with surgery and chemo-radiotherapy (where drugs and high-energy waves are used to treat cancer cells), however, Mr A's cancer was later found to have returned and spread further. Mr A died of widespread cancer later that year.

We took independent advice from a consultant ear, nose and throat (ENT) and head & neck surgeon. We found that there was an unreasonable delay in telling Mr A he might have cancer in his tongue and in carrying out surgery on Mr A's tongue, once the decision to treat it had been made. We also found that when Mr A later complained of pain in his shoulder, this should have been noted in his medical records and it was not. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in Mr A's care and treatment. 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:

• Patients suspected to have cancer should receive prompt treatment once the decision to treat has been made.
• The board should ensure that there is appropriate recording of reported symptoms at clinic appointments.

Summary

Mr C complained that Clear Business Water unreasonably charged him for water services for his business. Mr C's company trades from two units (Unit 1 and Unit  2) and had been paying another water service provider for both units. A number of years later, Unit 2 was allocated by Scottish Water to Aimera as a 'gap site' (a non domestic property that is connected to the Scottish Water Network and is yet to be registered. This means that although it is connected to the water system, the site has never been billed by a provider, as there are no records held for the property). Aimera contacted Mr C several years ago with regards to billing but Mr C explained that he was already paying another provider for both sites.

Mr C heard nothing more for nearly two years, when he received correspondence from Aimera regarding unpaid water charges. Clear Business took control of Aimera later that year and continued correspondence with Mr C in relation to the water charges. We found that Mr C's invoices from his current water provider were confusing as they mentioned both units but in fact they were only providing a service for Unit 1. Although this was not the fault of Clear Business Water's, we found that their communication with Mr C had been inconsistent and confusing. Mr C did not receive any correspondence for nearly two years and he did not find out the basis of his liability for Unit 2's water charges until Clear Business responded to his complaint.

We found that Clear Business failed to provide a reasonable explanation of the liability for water charges and we upheld Mr C's complaint. However, we considered that Mr C had notice he was liable for services for Unit 2 when he was contacted by Aimera about unpaid water charges and that it was reasonable for Clear Business to invoice from this date onwards. Any sums owed before that date, we recommended be written off.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the inconsistent and confusing communications and failure to clarify the position with respect to the liability for charges on Unit  2. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Write off the sums owed for consumption up to the date that Aimera contacted Mr C and waive any interest and payment rejection charges relating to that period. Offer a payment plan for the remaining outstanding sums.

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

• Communication with customers should be clear and easy to understand.

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 her father (Mr A) was inappropriately discharged from the Royal Infirmary of Edinburgh. Mr A had poor balance and mobility and had expressed his concerns about his ability to cope at home. Mr A fell shortly after discharge. After a number of hours, he managed to get help and was taken back to the hospital. Mr A was kept in hospital for another month due to a suspected infection.

We took independent advice from a nurse and a clinical adviser. We found that there had been a lack of discharge planning as to whether or not Mr A could safely cope at home and whether he required the assistance of carers or someone to stay with him. We also found that there were signs in the medical records which may have indicated that Mr A may have had an infection prior to discharge and that the signs were not acted upon. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to accurately determine if he was clinically fit for discharge and that there was a lack of discharge planning into whether he could cope at home. The apology should meet the standards set out in the SPSO guidelines on on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Clinical and nursing staff should ensure prior to discharge that an appropriate clinical assessment has been carried out. In addition that adequate consideration is given as to whether the patient is able to care for themselves on discharge.

Summary

Mr C complained on behalf of his wife (Mrs A) about the care Mrs A received at the practice. Mrs A had previously been diagnosed and treated for breast cancer. Six months after her treatment concluded she began attending the practice complaining of recurrent urinary tract infections and back pain. Six months following that it was found that the cancer had returned and spread to her bones.

We took independent advice from a GP. We found that the practice had carried out reasonable investigations when Mrs A first reported her symptoms. They had appropriately sought to investigate and exclude other possible causes of the symptoms Mrs A was presenting with. However, when Mrs A's symptoms did not resolve and investigations did not reveal a definite cause, the practice should have been alert to the possibility of a more serious underlying condition. We noted that referral guidelines for patients who have previously suffered from breast cancer note that unresolved back pain is a 'red flag' sign, indicating further serious investigation is required. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failure to provide a reasonable standard of care and treatment. 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:

• The practice should familiarise themselves with red flag signs and should ensure trainees are aware of this also.
• Ensure that the findings of this investigation are shared with the doctors involved in Mrs A's care and discussed at their next appraisal for shared learning and improvement in clinical practice.

Summary

Mrs C complained about the care and treatment she received on the labour ward at Victoria Hospital when she was admitted with a history of reduced fetal movement for 24 hours and no movement felt during the daytime. Mrs C complained that the decision to perform a caesarean section was unreasonably delayed and that once in theatre there was further delay in the delivery of her baby (Baby A) due to the difficulty in achieving an effective spinal anaesthetic. The board carried out a significant adverse event review (SAER, a structured approach to learning from an adverse event) which identified a number of failings in relation to the care and treatment given to Mrs C. Prior to our investigation, the board accepted that there had been a number of failings and detailed the action taken.

We took independent advice from a consultant obstetrician and gynaecologist (a  doctor who specialises in the female reproductive system, pregnancy and childbirth) and a midwife. We found that there were failings in relation to the clinical care given to Mrs C which led to the delay in the delivery of Baby A. We were also concerned that there had been a breakdown in communication regarding a post birth anaesthetic review and that there was no evidence that a proposed review meeting between Mrs C and the obstetric consultant had been offered, and either taken up or declined. We also noted that the SAER had failed to identify the anaesthetic involvement in the delay in the delivery of Baby A. In relation to midwifery care, we found that Mrs C's paper records had not accompanied her when she was transferred to another hospital. We considered that the care and treatment Mrs C received was unreasonable and upheld this aspect of her complaint.

Mrs C also raised concerns about the handling of her complaint. We found that the board had failed to comply with the NHS model complaints handling procedure. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in care, communication and complaints handling. 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 relevant medical staff, including locum medical staff, should be mindful of current clinical guidelines.
• Processes should be put in place to ensure transfers of care receive a post- operative anaesthetic review.
• Accurate and full clinical records should be maintained.
• All staff directly involved in care delivery should be included in the SAER process.
• All relevant paper records should accompany a mother on transfer to another hospital.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints procedure.

Summary

Mr C made a complaint about Clear Business Water (CBW) regarding charges for non-domestic water rates. Mr C was acting on behalf of a landlord who owned a building with multiple tenants. All of the tenants were paying their water rates individually and, therefore, the landlord was not liable for any charges. Mr C received an invoice for water and was told by CBW that the invoice was for a bulk meter which covered the water and waste liability for the whole property. They explained that the tenants were no longer paying this part of the bill. CBW advised that the previous meters were all deregistered from the market and the basis for the current invoices was correct. Mr C was unhappy with this response and brought his complaint to us.

We found that CBW had been approached by one of the tenants about changing the charging setup to a bulk meter. They stated that they spoke with a representative of the landlord (and colleague of Mr C) who agreed to the installation of the bulk meter.

We listened to a call between CBW and the representative of the landlord and were not of the view that consent was given to install a bulk meter, only that CBW could arrange for an initial survey into the matter. We noted that they had not notified Mr C when the account was created and this was something they were required to do under The Market Code. We also found that CBW failed to advise Mr C in initial correspondence that they were billing under The Deemed Contract Scheme where the scheme requires this to be clearly identified to customers. Overall, we found that while the charges were technically correct and liable, the communication from CBW had been poor. We found that the account did not have the authority of the landlord to be created as they did not approve the installation of the bulk meter. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for their poor communication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• CBW should waive the outstanding balance on Mr C's account in light of the failings identified.

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

• CBW should ensure that correspondence sent to customers under a deemed contract is updated to clearly highlight this, as is required in The Market Code.
• CBW should ensure that the findings of this complaint are shared with staff in a supportive manner, to ensure that the requirements of the Market Code when a gap site is allocated are adhered to.

Summary

Ms C complained about the way that the council handled her complaint. Ms C was unhappy with the council's decision to change investigating officers late on in the process and to appoint a different officer. Ms C said the council had done this because they were unhappy with the conclusions of the first investigation, which had been critical of the council. She noted that the second investigation had reached a conclusion that was much less critical. Ms C was also unhappy with the way her Complaint Review Committee (CRC, the process previously used to investigate social work complaints) was conducted. She said there had been unexplained delays in holding the hearing and that, following the hearing, the council had issued an inaccurate decision letter which did not reflect the views of the panel.

We took independent advice from a social work adviser. We found that the council had acted unreasonably in the way that they handled the investigation and the way they administered Ms C's CRC hearing. The council had failed to evidence the reasons they gave for changing the investigating officer. They had also failed to keep records of the review of the first investigation, which led to the decision to change investigating officer. We noted that council staff also appeared to have attempted to influence the decision issued by the CRC after the hearing had concluded. Finally, we considered that the council had failed to communicate reasonably with Ms C following the CRC and it was unclear whether the council had accepted all the findings of the CRC and intended to implement them. We upheld all of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her family for failing to handle her complaint reasonably or appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• The council should reflect on the failings identified by this investigation to ensure that all relevant learning has been fedback to staff.