Upheld, recommendations

Summary

C complained on behalf of their parent (A) who passed away in hospital. During the admission, A was diagnosed with B cell lymphoma (a type of blood cancer) and received palliative radiotherapy treatment.

C complained that A’s pain medication was incorrectly managed as they experienced both delirium and extreme pain, that A’s nutrition and fluid intake was incorrectly managed as A became dehydrated and lost weight, that A was left in a general ward rather than being moved to a cancer ward and that A was not offered chemotherapy. C complained that there had been a lack of communication regarding A’s palliative treatment plan, A’s deterioration and death.

The board advised that A’s pain medication had been appropriately reviewed and adjusted. C’s fluid intake was difficult to manage but there was no indication for nasal gastric feeding. They apologised that there were gaps in the records in relation to fundamentals of nursing care, including nutrition, fluids and skin care and that nurses had since undertaken training. They noted that A was deemed too unwell to tolerate chemotherapy or a move and they stated that a number of discussions took place with the family to explain A’s changing condition.

We took independent advice from a consultant geriatrician, a registered nurse and a consultant haematologist. We found that A’s pain had been reasonably controlled and the decision not to offer chemotherapy was reasonable. However, medical staff should have considered nutrition support earlier and nursing care had been unreasonable in relation to nutrition, fluids and skin care. Communication from doctors and nurses on the ward was reasonable, but there had not been any communication from a specialist about A’s cancer prognosis and palliative radiotherapy treatment. Therefore, we upheld all aspects of this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that no specialist explained the lymphoma diagnosis and treatment plan to 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 C that nursing care and recording was unreasonable, in regards to pain assessment, nutrition, hydration and skin care. Apologise to C that medical staff did not offer nutritional support at an earlier stage. 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:

• Person centred care plans should be recorded and followed for each patient. If radiotherapy patients are treated in general wards, nursing staff in those wards should be trained on how to manage radiotherapy skin damage. Nutritional support should be considered for vulnerable patients and medical staff should be aware of alternative methods of weight loss assessment in patients with oedema.
• A specialist explains the cancer diagnosis and treatment plans to the patient and family.

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

Summary

C complained about the care and treatment that their spouse (A) received from the board whilst they were a patient of the cardiology ward. C complained that A collapsed on arriving home having been discharged after undergoing a coronary angiogram (a type of x-ray used to take pictures of the heart’s blood vessels, the coronary arteries) and stenting procedure. A was found to have experienced a vascular complication (a large haematoma, where blood leaks from a large blood vessel) in front of the femoral artery (the main blood vessel supplying oxygen rich blood to the lower body) and had surgery to remove the haematoma. Following the second surgery, A developed an infection in the wound site.

The board said that due care was taken to weigh up the risks and benefits of various treatments in A’s case. Whilst there were signs of a haematoma at the puncture site after the procedure, this was not increasing in size when A was discharged, and A’s blood pressure was normal.

C complained to SPSO highlighting concerns about the decision to carry out an angiogram, the decision to discharge A, infection control and failures to follow protocol and use an ultrasound to assess the puncture site.

We took independent advice from an appropriately qualified consultant cardiologist. We found that carrying out an angiogram was appropriate in the circumstances. We considered the care and treatment following the procedure and on A’s readmission to be reasonable. However, there were a number of factors which should have triggered staff to consider delaying discharge and seeking an ultrasound scan. We found that the need for an ultrasound scan was clinically indicated and that the decision to discharge was unreasonable. As such, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The threshold for considering an ultrasound scan should be lowered for patients who have a higher bleeding risk and who develop painful haematomas post procedure. A lack of pulsatile haematoma should not preclude performing an ultrasound scan if there is clinical concern.

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

Summary

C complained that the practice unreasonably refused to offer a face-to-face appointment to their child (A) who is immunosuppressed with asthma and had a cough for over three weeks.

The practice advised that if A had shown symptoms of shortness of breath or wheezing, a face-to-face appointment would have been arranged. C did not identify these symptoms and so C was advised to double the dose of A’s inhaler and get in contact if A worsened. It was also noted that A had an appointment with paediatrics later that day.

We took independent advice from a GP. We found that it was not reasonable to rely on a parent / carer to determine whether a child is wheezing or short of breath. A was immunosuppressed and at higher risk of infection. While it is acknowledged that A had a paediatrics appointment later that day, there is no record that this rationale for declining to see A was a factor in their decision making at the time. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

• The clinicians involved should reflect on the findings of this case and the relevant guidelines.

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

Summary

C, a support and advocacy worker, complained that the board failed to provide reasonable nursing care and treatment to their client (A).Specifically, they had concerns that while A was a patient in hospital, there was an unreasonable lack of attention, poor attitude from nursing staff and unreasonable nursing care. C was also unhappy about the board’s complaint handling.

We took independent advice on this complaint from a nursing adviser. We found that the board’s nursing documentation was a poor standard, not in line with guidance and was in breach of the Nursing and Midwifery Council: The Code requirements. We also found that board’s lack of documentation had led to the board being unable to evidence that care was carried out to a reasonable standard. Lastly, we found that the board unreasonably failed to respond accurately to the complaint. We therefore upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for breaching the NMC Code requirements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the failings around poor person centred care planning and poor record keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully and accurately to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

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

Summary

C complained about the care and treatment provided to their late spouse (A) by the practice. A was provisionally diagnosed with torticollis (where the head becomes persistently turned to one side associated with painful muscle spasms) by the practice. Six months later A was admitted to hospital and diagnosed with transitional cell carcinoma (a type of bladder cancer) and a secondary tumour was growing on the spine. A died a few month's later. C complained that the practice failed to provide a reasonable standard of care and treatment in the months before A’s diagnosis and once A was discharged from hospital.

We took independent advice from a GP. We found that the practice unreasonably failed to arrange face-to-face appointments, or carry out more detailed clinical examinations, history taking and assessment of red flag symptoms. There was a lack of continuity in the care A experienced and it was unreasonable that there was a delay in actioning a referral upgrade to urgent. While we accepted that there was a poor prognosis, earlier intervention might have improved the management of A’s pain. Therefore, we upheld this part of C's complaint.

In relation to A's care after their hospital admission, we found that it was unreasonable that A was not reviewed by a GP until seven days after discharge and not directly examined by a clinician when they reported a new symptom. We also noted that no detailed assessment was carried out of A’s analgesic (painkiller) requirements. We found that the practice did not provide reasonable care in accordance with the relevant standards on discharge. Therefore, we upheld this part of C's complaint.

We also found that while the practice completed a Significant Event Analysis, this learning could have been carried out in a more timely way. We noted that the practice's own complaint investigation did not identify the full extent of the failings in this case. While areas for learning and improvement have been recognised and acknowledged by the practice, these were only identified in response to our enquiries.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the principles/standards set out in SPSO’s guidance on apology available at www.spso.org.uk/meaningful-apologies.

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

• Wherever possible and where it is clinically appropriate, patients should receive face-to-face appointments, where a detailed clinical examination can be carried out, a detailed history taken and assessment of any red flag symptoms, and receive continuity of care.
• Patients with new diagnoses of cancer should receive prompt review by a GP, including appropriate Anticipatory Care Planning, completion of an eKIS summary and be added to a Palliative Care disease register to facilitate multi-disciplinary care planning.
• When a relevant adverse event occurs, the practice should promptly carry out an appropriate adverse event review to investigate the cause and identify any potential learning in line with the National Framework for Scotland (www.healthcareimprovementscotland.scot/).

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should ensure that failings, as well as good practice are identified and that learning and information gathered from complaints is used to drive service improvement.

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

Summary

C was diagnosed with a kidney stone by a neighbouring board. Shortly after, they attended Greater Glasgow and Clyde's Urology Department and received an X-ray. C complained that the board failed to identify the kidney stone, resulting in surgery several weeks later and a kidney injury.

We took independent advice from a consultant urologist. We found that while it was not possible to determine whether the board failed to identify a kidney stone on the X-ray, the board did have doubt about whether the stone had passed. At this point the board should have checked this by means of a CT scan. We found that it was not possible to determine whether failing to confirm a kidney stone, and delayed treatment, would result in a kidney injury. We upheld this part of the complaint because it was unreasonable for the board to have doubt about whether there was a stone present, but not to confirm this.

C complained that the board had failed to arrange a follow-up appointment within an appropriate time period. We found that when passage of the stone was not confirmed, a follow up CT scan should have been arranged within 2 weeks, and that the plan to wait a further 6 weeks in these circumstances was unreasonable. Therefore, we upheld this part of C’s complaint.

C also complained that the board did not clearly communicate their diagnosis, and their subsequent request for clarification on how they came to have surgery after being told there was no kidney stone present. We found that there were shortcomings in the board’s communication with C, both in relation to the kidney stone and in providing an explanation as to how they came to have surgery. Both of these might have been relatively easily avoided or resolved. We therefore upheld this part of C’s complaint.

We asked the board to reflect on the imprecision of using plain X-rays and consider the possibility of updating practice by using low dose non-contrast CT scans as standard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process failings identified in respect of their complaints. 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 should have a full understanding of what is happening in relation to their diagnosis and ongoing treatment plan. The board should ensure that patients are sign posted to the relevant complaints procedure when they raise concerns.
• Relevant staff should be aware of the requirements of ensuring that patients are stone free, either by spontaneous passage or clinical removal after 4 to 6 weeks of initial presentation, in accordance with the relevant 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.

Summary

C complained that the board failed to provide them and their baby (A) with appropriate care and treatment both during and after A’s delivery at the hospital. This included failing to advise C that one of the doctors involved in the delivery of A was a first year speciality trainee doctor and that the use of forceps in A’s delivery resulted in them suffering permanent injuries, erb’s palsy (a condition often caused by birth trauma that can affect the movement and feeling in a baby's arm) and phrenic nerve palsy (respiratory distress which can be caused by nerve damage during birth). C also complained that there was a failure by the board to carry out further investigations of A’s erb’s palsy, a failure to deal with A’s respiratory distress and diagnose that they had phrenic nerve palsy and a failure to adequately monitor A’s weight.

We took independent advice from two medical advisers, a consultant obstetrician and gynaecologist and a consultant neonatologist.

We found that birth injuries could occur even though there were no obvious difficulties with the birth. Given this and the evidence available, it was not possible to establish the cause of A’s injuries. However, we found there was a lack of communication with C during the consent process, C was not consented for the involvement of junior trainee speciality doctors at the birth of A and it was not explained to C that teaching of staff would take place during the birth. We found that no consideration was given to the use of ultrasound to determine the position of A prior to delivery, in accordance with Royal College of Obstetricians and Gynaecologists guidance, and medical documentation around the events of A’s birth was not of the expected standard in terms of the level of detail recorded. We, therefore, upheld this part of C’s complaint.

In terms of the care and treatment of A following delivery, we found that, overall, this was reasonable. We found that there were no concerns about the diagnosis and treatment of A’s Erb’s palsy and that A did not have respiratory problems, or the key signs associated with phrenic nerve palsy. However, we found that the board failed to adequately monitor A’s weight during their hospital stay, which was acknowledged by the board, and we upheld this part of C’s complaint on that basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be informed when junior trainee speciality doctors are to be involved in their care and treatment and when teaching of staff will be included. These discussions should be clearly recorded as part of the consent process. The following issues should be included in the board’s guidance on obtaining consent: (i) staff should provide an explanation to the patient as to who will be overseeing the birth, and if they will be assisted by other doctors in training; (ii) that members of the clinical team introduce themselves to the patient and explain what their role will be.
• Routine consideration should be given to the use of ultrasound for determining and confirming the position of the fetal head in accordance with the RCOG Guidance, especially when rotation of the baby is required.

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

Summary

C complained on behalf of their parent (A) about the care and treatment A received from the board while they were in hospital.

C complained that the hospital failed to consider the relevant medical and practical considerations, particularly with respect to A’s medication and whether it may have contributed to delirium and the falls A suffered while in hospital. C also complained that the board had failed to adequately consult with family members when the decision was made to discharge A. C further complained that the board’s handling of their complaint was unreasonable.

We took independent advice from a consultant specialising in the care of the elderly. We found that C had raised legitimate concerns that the medication could contribute to delirium and the risk of falls. It appeared that the dose prescribed had changed on a number of occasions without a clear rationale recorded in the records and that the care provided with respect to prescribing and monitoring A’s medication fell below a reasonable standard. We therefore upheld this aspect of the complaint.

We also identified a lack of detail in the pre-discharge assessment of A, and a lack of discussion with the family. We upheld this aspect of the complaint.

Lastly, there were elements of C’s complaint that were not adequately or accurately addressed in the board's complaint response and on this basis we upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• A patient’s suitability for discharge should be appropriately assessed. The rationale for discharge should be properly documented and any relevant documentation completed. Where appropriate, the patient’s family should be included in discussions about planning for the patient’s discharge.
• Decisions about medication prescribed for a patient and any changes to that medication should be accurately recorded in the patient’s medical records and contain details of all pertinent information.
• Staff are aware of the importance of prescribing and monitoring a patient’s medication appropriately.

In relation to complaints handling, we recommended:

• Complaint responses should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaint responses should address the key issues raised, should be factually accurate and should acknowledge the concerns of the complainant.

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

Summary

C complained about the care and treatment that their late parent (A) received during their attendance at A&E. A was seen in A&E as a GP referral to the hospital’s medical team. C complained that the medical team failed to recognise the nature and severity of A’s condition and their general vulnerability, that they failed to institute an appropriate and timely treatment plan and that there was a failure in record keeping. C also complained that A was discharged home without appropriate medication, without an appropriate discharge letter and without alerting their family and that the board had ignored their Duty of Candour and Ethics Code.

When responding to C’s complaint, the board accepted that there were failings in relation to some aspects of A’s care and treatment. They apologised that C had not been informed about A being discharged. They explained that this had been shared with relevant staff and that they were making changes to ensure families and carers were contacted prior to the patient being discharged. The board also accepted that A should have been provided with a copy of their discharge letter given their vulnerability. They explained that consideration would be given to printing off discharge letters and giving them to medical patients in certain circumstances. Further, the board accepted that there had been failings in relation to record keeping and in relation to A’s medical notes. They indicated that this would be brought to the attention of the relevant staff, would be part of the medical induction and would be discussed in a clinical forum.

We took independent advice from a consultant in emergency medicine. We found that the care and treatment given to A whilst in A&E was reasonable as was the decision to discharge A. There was no evidence to suggest that A's death was linked to any aspect of the care and treatment they received in A&E. However, we found that, in addition to the failings identified by the board that are detailed above, there was no evidence that the board had any process in place to examine this type of case to ascertain whether it met the threshold for a Significant Adverse Event Review (SAER). We upheld the complaint.

We also found that there was a failure by the board to fully address the issues raised when responding to C’s complaint and that there were undue delays in updating C and responding to them about their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• There should be clarity around the board’s policy and processes for identifying and initiating a SAER (Significant Adverse Event Review) in cases where a patient has come to series harm (death) shortly after discharge.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Additionally, learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

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

Summary

C, a support and advocacy worker, complained on behalf of their client (A) who had looked after their grandchild since the sudden death of the child’s parent (B). A approached the council for both general and financial assistance. In particular, to support them in obtaining a residence order (a court order that regulates the arrangements made about where a child lives). The council decided that A was not eligible for financial support to apply for an order or for a kinship care allowance. A was later granted a residence order.

C complained to the council. The council confirmed that A had not been initially entitled to a kinship care allowance. However, following the granting of the order a kinship allowance was granted and was backdated to the date of the order.

We took independent advice from a social worker. We found that the assessment carried out by the council when the child was placed in A’s care was reasonable and in line with guidance and legislation. However, there had been a failure to initiate appropriate follow-up and support when A contacted them again a few months after the assessment. We also found that there had been a failure to action referrals to other agencies who could have offered support to A. In addition, we found that there had been a failure to provide written evidence that they had fully reviewed the information provided by A when they contacted them after the assessment or that they had contacted A at the conclusion of the review. Finally, there had been a failure to capture critical information in the case records. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Staff should be reminded that kinship procedures are not only about financial support but about offering practical parenting advice and support to kinship carers. Staff should be reminded of the importance of recording critical information, including action taken and decision-making consideration in case notes.

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.