Upheld, recommendations

Summary

Ms C complained that the practice unreasonably referred her to the community mental health team. The practice had been contacted by the social work department and the police about Ms C and, in response, the practice referred Ms  C to the community mental health team without discussing it with her or seeking her consent. Ms C complained about the referral saying that it was unreasonable in the circumstances.

We took independent advice from a medical adviser. We found that the practice did not follow the relevant guidance when they referred Ms C, and that referring her without her knowledge or consent was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for referring her to the community mental health team withouther knowledge and consent. 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 follow the relevant guidance when they refer patients.

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

Summary

Ms C complained about the medical care and treatment and the nursing care provided to her late mother (Mrs A) at Royal Alexandra Hospital. Mrs A was admitted to the hospital with a urinary infection. Mrs A was discharged from the hospital and readmitted within a few hours. Mrs A had a seizure while in hospital and sustained a broken leg.

We took independent advice from a consultant in acute medicine. While the board provided reasonable medical care in a number of areas, we found that the board failed to:

• take steps to increase Mrs A's sodium levels and monitor the effect of this on her delirium prior to discharging her

• ensure that Mrs A received a prompt review from medical staff following her seizure

• administer anti-seizure medication to Mrs A because stocks were not available on the ward

• ensure that Mrs A's records made it clear that she had a fractured leg

We also took independent advice from a nursing adviser. In relation to Ms C's complaint that the board did not provide reasonable nursing care to Mrs A, we found that there were a number of failings. In summary the board failed to:

• ensure the recording regarding Mrs A fluid and nutritional needs followed the appropriate policy and guidance

• record the use of a red silicone mat at mealtimes

• record the date Mrs A's special diet was ordered

• record Mrs A's oral care needs and what oral care was provided

• record Mrs A's episodes of pain

• record Mrs A's specific personal care needs and the frequency that personal care was required in her care plan

• complete a multidisciplinary moving and handling care plan

• involve Mrs A and her family in the assessment and care planning process

• record the physical assessment carried out by nursing staff following Mrs A's seizure

• update Mrs A's care plan to detail what her post-fracture needs were.

In view of these failings we upheld Ms C's complaints that the board did not provide reasonable medical care and treatment and nursing care to Mrs A. We also found that the board did not identify these failings during their own investigation of Ms C's complaints and made recommendations in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mrs A with reasonable medical and nursing care. The apology should meet the standard 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 with low sodium levels should not be discharged without attempts to increase them.
• Patients who have a seizure should be reviewed promptly by medical staff.
• Where prescribed medication is not available on the ward, this should be obtained from another ward or the pharmacy and administered accordingly.
• Fractures should be recorded clearly in patient medical records.
• Patients should receive adequate nutritional, hydration and oral care assessment and care planning in accordance with the relevant standards.
• Patient food and fluid recording charts should be completed in line with policy and guidance.
• Nursing assessments and care plans should clearly document the care needs of patients and what care has been provided.
• Where appropriate, assessments, care plans and reviews of care should be completed in collaboration with patients and their family members.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified and enable learning from complaints to inform service development and 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

Ms C complained about the care and treatment that her mother (Mrs A) received when she attended the emergency department at Queen Elizabeth University Hospital. Mrs A attended the hospital with severe headaches and pain radiating down her face and mouth. Ms C said the consultant who dealt with Mrs A failed to consider her reported symptoms properly, failed to carry out a thorough physical examination of Mrs A and instead referred Mrs A to her GP.

We took independent medical advice from a consultant in emergency medicine. We found that as Mrs A did not present with features of an immediate life threatening condition, it was safe and reasonable to redirect her to her GP. However, we found that the triage process (the process for sorting patients in an emergency department according to urgency) for patients presenting with headache was not followed in Mrs A's case, and information which should have been obtained and recorded was not. The board should also have provided Mrs  A with a redirection leaflet which explained the redirection process. On balance, we considered that the board did not provide Mrs A with appropriate care and treatment and we upheld this part of the complaint.

Ms C also complained that the board unreasonably failed to send a report to Mrs  A's GP following her attendance at the hospital. We found that the board should have sent a letter to Mrs A's GP, but failed to do so. Therefore, we upheld this part of the complaint.

Ms C also complained that the board unreasonably delayed in responding to her complaint. The evidence showed that while there were delays in obtaining formal consent from Mrs A for Ms C to make a complaint on her behalf, there were also unreasonable delays by the board in their handling of Ms C's complaint. Therefore, we upheld this part of the complaint.

At the beginning of our investigation into this complaint, the board failed to provide us with the correct version of their redirection policy which resulted in a delay in our decision making. Therefore, we made a recommendation to the board in light of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C, her family and Mrs A for failing to follow their triage process in Mrs A's case and obtain and record information on Mrs A; failing to give Mrs A a redirection leaflet; not sending a report to Mrs A's GP following her attendance at the emergency department; and unreasonably delaying in responding to Ms 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:

• Patients triaged within the emergency department should have their observations appropriately documented in line with the board's triage guidelines.
• Patients who are being redirected under the board's Redirection Policy should be provided with a redirection leaflet and this should be documented in the clinical records.
• In a similar situation, the patient's GP should be appropriately contacted on discharge from the emergency department.

In relation to complaints handling, we recommended:

• Complaints should be responded to in accordance with the board's complaints handling policy/procedure.
• The board should ensure that the correct documentation is provided at the appropriate point in an SPSO investigation.

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 medical care and treatment he received when he attended Queen Margaret Hospital to have biopsies (a procedure to remove tissue or cells for analysis) carried out. In particular, Mr C complained that, despite telling the operating surgeon that he was in extreme pain the biopsy procedure was continued. He also said that during the consent process for the biopsy procedure, he was not advised there was a risk of major bleeding.

We took independent advice from a consultant urological surgeon (a specialist in diseases of the urinary organs in females and the urinary tract and sex organs in males). We found that the operating surgeon should have stopped or acted to address Mr C's discomfort during the biopsy procedure. We were also concerned that, although uncommon, the risk of major bleeding was not explained to Mr C. While we found that the care and treatment Mr C received following the biopsy procedure was reasonable, we were concerned that the level of communication in relation to the discharge letter was unreasonable. Therefore, we upheld Mr  C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in relation to the decision to continue the biopsy, the consent process and communication. 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 who display signs of distress during a procedure should have this acted on in line with guidance and standards.
• Patients should be appropriately informed of the risks following prostrate biopsies in line with national guidance on consent.

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 about the nursing care provided to her father (Mr A) at Dumfries and Galloway Royal Infirmary. Ms C raised a number of concerns including:

• Mr A having suffered a fall that resulted in a wound to his arm;

• the suitability of his diet;

• his developing of a pressure ulcer;

• him not seeing a dietician and;

• poor record-keeping, specifically the failure to record her father's fall.

We took independent advice from a nurse. We found that risk assessments about the risk of developing a pressure ulcer and being nutritionally compromised had not been completed correctly. This resulted in Mr A not receiving adequate pressure ulcer prevention interventions and being assessed at a lower risk of being nutritionally compromised than he should have been. We also found that important records relating to fluid intake and weight were not kept up to date and that the board failed to follow their policy when they became aware of Mr A's fall. We considered the care and treatment Mr A received was unreasonable and upheld this complaint.

Ms C also complained about the board's responses to her complaints. Ms C was concerned about the tone of the board's response, whether the response reasonably addressed the complaints she raised, the time taken to respond and the efforts to communicate the response when it was clear Mr A was in the final days of his life. We found that the tone of the response had been reasonable but not all of the issues raised had been responded to and that some of those that were, were unreasonable. We found that the response had been provided within a reasonable timescale but the board had not acknowledged Ms C's complaints as they should have. We found that it was unreasonable for the board to have refused to read their decision letter, which was awaiting a final signature, to Ms  C over the telephone so she could communicate it to Mr A before he died. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide reasonable care to Mr A during his admission to hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for not responding reasonably to her complaints about Mr A's time in hospital. 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 board should ensure they are following the Healthcare Improvement Scotland Standards for Prevention and Management of Pressure Ulcers (2016). The standards clearly lay out what is expected in terms of leadership and governance; education, training and information; assessment of risk for pressure ulcer development; reassessment of risk; care planning for prevention and treatment and; assessment, grading and care planning for identified pressure ulcers.
• The board should ensure that they are following the Healthcare Improvement Scotland Standards for Food, Fluid and Nutritional Care.
• The board should ensure that all staff follow their Falls Risk Assessment policy.

In relation to complaints handling, we recommended:

• The board should appropriately respond to the points of concern within complaints. The board should ensure that each aspect of the correspondence is addressed.
• Complaints should be dealt with in accordance with the model Complaints Handling Procedure (CHP).

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 about the care and treatment that her mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. She was admitted to hospital with a large haematoma (a localised collection of blood outside the blood vessels) on her right leg. Mrs A received treatment and was later discharged. After a visit from the district nurse, Mrs A was readmitted to hospital and her leg was operated on the following day. Mrs A was eventually discharged to a hospital outwith the board. Mrs C complained that the board failed to provide appropriate treatment for Mrs A's haematoma following her admission to hospital. She also complained that the board unreasonably discharged Mrs A from hospital.

We took independent advice from a registered general nurse and a consultant in general medicine. We found that there was a lack of wound assessment, inappropriate wound assessment and a failure to debride the wound (to remove the damaged tissue from the wound) before discharge. We were also concerned about the use of dressings which stuck to Mrs A's leg and considered Mrs A should have been referred to a wound care specialist. We considered that these failings would have contributed to the time taken for Mrs A's wound to heal and her pain during that period. Initially Mrs A received appropriate medical care, with appropriate investigations carried out on admission and clear attention to detail. However, we found that Mrs A should have received a greater level of medical review prior to discharge, and her care therefore fell below a reasonable standard. We upheld this part of Mrs C's complaint.

In relation to Mrs A's discharge, we found that Mrs A should have received a debridement before discharge. We were also concerned about the level of medical review Mrs A received in the days before her discharge. Given the severity of Mrs A's wound a few days later, and the lack of detail in the records at the time of discharge, we were not confident that Mrs A's wound had improved significantly and enough for Mrs A to return home safely. Therefore, we considered Mrs A's discharge to be unreasonable and upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failing to appropriately assess and document the wound on admission, correctly assess the wound, apply appropriate dressings, debride the wound and, refer Mrs A to a wound care specialist. 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 in a similar situation should have a wound chart completed on admission and updated at every dressing change.
• From admission, a wound should be measured using a measuring scale to ensure accuracy of size. Staff should be knowledgeable on the type of tissue that is present on the wound bed and be competent in this prior to completing a wound assessment chart.
• A non-adherent contact layer or non-adherent dressing should be applied to the wound bed. Gauze swabs should not be used as a wound dressing.
• Where appropriate, a wound bed should be debrided without surgical intervention prior to the patient being discharged home.
• Patients should typically be seen by a doctor at least once a week.

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 the university had failed to respond to her complaint within a reasonable timeframe. Ms C submitted her complaint to the university but had not received a response by the time she contacted us ten months later.

We found that the university had appropriately handled the complaint at Stage 1 of their complaints process and had also kept Ms C reasonably informed of the progress of her complaint at Stage 2 of the process. However, we considered that it was unacceptable for Ms C to have still not received a response to her complaint ten months later and the university had been unable to provide an indication of when a response might be ready. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Respond to Ms C's complaint.

In relation to complaints handling, we recommended:

• The university should ensure that they have the most efficient system for processing complaints, to minimise unreasonable delays in the face of limited resources.

Summary

Mr C complained that he did not receive his meals in prison when he was off his work placement for a week. He has a nut allergy and had requested to be placed on a special diet list. His work placement was within the kitchens so he was usually able to prepare his own meals. However, he complained that he was not placed on the special diet list, resulting in him not receiving meals when he was off work.

In responding to his complaint, the prison indicated that Mr C had not been on the special diet list, but had since been added to it following receipt of confirmation of his allergy from the healthcare team. However, the prison then told us that no instruction had been received from the healthcare team indicating any special dietary needs that Mr C could not manage himself. They acknowledged there had been issues in the past with Mr C not receiving the correct meals, which led to him being offered a job in the kitchens.

While we considered that the prison had demonstrated flexibility in allowing Mr C the freedom to control his food intake, we were unable to conclusively determine the arrangements in place to ensure his dietary needs are met when he is not working in the kitchens. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to clarify the confusion surrounding his dietary requirements, which led to him not receiving some meals.

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

• The prison should write to Mr C to clarify what arrangements are in place to ensure his dietary needs are met, with a copy to kitchen staff and a copy to our office.

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 the Scottish Government failed to respond to her complaint within a reasonable timeframe. Ms C came to us after waiting a number of months for a response to her complaint. We contacted the Scottish Government five times over the course of four months to request an update on Ms C's complaint. When they failed to provide Ms C with a response within the timeframe we set, we accepted a complaint from Ms C about the Scottish Government's handling of her complaint.

During the course of our investigation, the Scottish Government replied to Ms C's complaint. We found that they had failed to refer Ms C to us at the the end of their complaints process and failed to provide us with information we requested by the deadline set. We considered that the Scottish Government failed to respond to Ms C's complaint within a reasonable timeframe and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to respond to her complaint within a reasonable timeframe, keep her updated about delays and refer her to our office at the end of the complaints procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• The Scottish Government should follow their Complaints Handling Procedure. They should reflect on the poor handling of Ms C's complaint and set out what action they are taking to prevent similar errors occurring in future.
• The Scottish Government should reflect on the poor handling of our enquiries and set out what action they are taking to ensure more effective communication channels in future. Support can be found through the Complaints Standards Authority: http://www.valuingcomplaints.org.uk/.

Summary

Mr and Mrs C complained that primary school staff failed to follow procedures in relation to their reports of their child being bullied, and about the council's handling of their complaint.

We found that council policy required that if a bullying incident was reported, it should be investigated to establish whether bullying had occurred, and that school management would monitor and keep records of incidents from all classes, identifying possible patterns of behaviour. Class teachers would follow- up any complaint by a parent and report back promptly and fully on the action taken; investigate an incident if bullying was suspected or reported, with the incident being dealt with immediately by the teacher approached; and monitor and record conflicts on pastoral notes and advise the Senior Management Team of this. We were not provided with any records that investigations took place, in response to Mr and Mrs C's contact, to establish whether bullying had occurred. We upheld this aspect of the complaint.

Mr and Mrs C submitted a detailed complaint to the council. In our view, the council should have dealt with it at the investigation stage of the complaints handling procedure, rather than trying to deal with it at the frontline resolution stage. After this, the council carried out an investigation outside the complaints handling procedure and, after this, a second investigation as part of the complaints handling procedure. We found that the council's responses to Mr and Mrs C, in particular after the first investigation, did not deal with the complaints they had raised, or provide reasonable responses to key points. We upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for unreasonably failing to follow procedures in relation to their reports of their child being bullied. 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:

• School staff should ensure that they follow the council's and the school's anti-bullying policies, and keep adequate records.