Upheld, recommendations

Summary

Mr C complained that the board delayed in providing him with surgery for his feet and knees, and that they unreasonably failed to explain the reasons for the delays.

We took independent advice from an orthopaedic surgeon (a surgon who specialises in the musculoskeletal system). We found that the Treatment Time Guarantee places a legal requirement on health boards so that, once planned treatment has been agreed with the patient, the patient must receive that treatment within 12 weeks. We found that Mr C waited around six months for the surgery on his first foot, and then ten months before being seen by a knee surgeon. We found that, whilst medically Mr C came to no harm as a result of the delays, he clearly suffered pain and functional restriction for longer than was reasonable. We upheld this aspect of the complaint.

Regarding communication, we noted that Mr C had received a letter confirming a guarantee of treatment within 12 weeks for his first surgery. The next documented communication was several months later, and was only sent in response to contact from Mr C. We considered that there should have been further communication from the board, apologising for the delay and setting out the steps being taken to minimise this. We found that Mr C had been left for many months without knowng when he might receive surgery. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in his orthopaedic treatment.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to explain the reasons for delays in treatment, and for failing to keep Mr C updated with regard to when he could expect to have his surgery.

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

• In the event that the Treatment Time Guarantee is not going to be met, letters to patients should make this clear, in accordance with the Patient Rights (Scotland) Act 2011.
• Be clearer with patients about any delays, the reasons for the delay and the steps being taken to improve matters.

Summary

Ms C began to experience stiffness and pain, to the extent that she was struggling with everyday tasks. Her GP prescribed her steroids (a type of anti-inflammatory medicine), which improved her symptoms. Her GP then referred her to rheumatology (the branch of medicine concerned with immune-mediated disorders of the musculoskeletal system) at Royal Alexandria Hospital. Ms C complained that, when she attended her rheumatology appointment, her condition was not appropriately assessed. Ms C said she was told to stop taking steroids but when she did this, her symptoms returned. Ms C raised concerns that she was not given any follow-up appointment to check on her condition. She also complained that, when her GP raised concerns about her worsening symptoms with rheumatology, no action was taken.

We took independent advice from a consultant rheumatologist. We found that there was a lack of useful clinical information in the clinic note and GP letter relating to Ms C's initial rheumatology appointment. As a result, the adviser was unable to confirm if her assessment was reasonable or not. We found that consideration should have been given to reducing Ms C's steroid dose gradually before it was stopped. We found that Ms C should have been given a follow-up appointment or the means to contact rheumatology directly for advice if her symptoms returned. We also found that when her GP contacted rheumatology with concerns, Ms C should have been offered a prompt review. In addition, we found that phone conversations, in which advice was given to Ms C's GP, were not recorded in her medical records.

We found that due to these failings, there was an unreasonable delay in diagnosing Ms C's underlying condition of inflammatory arthritis (an autoimmune condition that causes joint pain and swelling). We upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately document and update both Ms C and her GP on her rheumatology appointment; not giving Ms C a follow-up appointment or the means to contact rheumatology directly for advice; and the delay in offering Ms C a rheumatology review when her symptoms returned and worsened. 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:

• Appropriate clinical information should be documented in clinic notes, given to GPs and copied to the patient, with enough detail to understand how a clinical decision or diagnosis has been reached.
• Patients should receive appropriate follow-up care and a prompt rheumatology review if required.
• Clinical advice, which is given to GPs, should be recorded appropriately.

Summary

Ms C complained on behalf of her mother (Mrs A). Mrs A was discharged from Gartnavel Hospital and then re-admitted two days later with a urinary tract infection and fluid on her lungs. Ms C complained that the board failed to discharge Mrs A in a reasonable way.

We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that, medically, it had not been unreasonable to have Mrs A discharged. While she may have had both a urinary tract infection and fluid on her lungs at the point of discharge, these were not doing her harm at that point. However, we found that Mrs A's risk of falls had not been adequately assessed prior to her discharge, and that this risk had also not been adequately communicated to Ms C. We noted that more should have been done to assess and reduce Mrs A's risk of falling before she was discharged, and that it was unreasonable to have discharged her due to her mobility issues. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mrs A for failing to assess Mrs A's falls risk prior to her discharge, and for failing to communicate this risk to Ms C. 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 at high risk of falls should be adequately assessed prior to discharge. Plans should be put in place to manage a patient at high risk of falls prior to their discharge.

Summary

Mr C's child (Child A) was born with several rare conditions that threaten life, affect physical and mental development and require extensive clinical and day- to-day management. Mr C complained that the board unreasonably failed to identify any indication of developmental conditions from scans of Child A during his partner's pregnancy. The board said that Child A's conditions were not identified earlier because they were either not detectable by ultrasound at any stage of pregnancy, were not part of the routine checks undertaken or appeared to be within normal limits for the relevant stage of pregnancy. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from an obstetric and sonography adviser (a specialist in the use of ultrasound in pregnancy). We found that Child A's kidneys did not appear normal in the 20 week scan and that immediate referral to a specialist would have been reasonable practice in those circumstances. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Acknowledge that they unreasonably considered Child A's kidneys appeared normal on the 20 week scan, and apologise to Mr C for this. 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:

• A risk management multidisciplinary review should be undertaken about the board having missed the abnormality in Child A's kidneys.

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client Mrs A about the care and treatment Mrs A received at Dr Gray's Hospital. Mrs A suffered a miscarriage and attended hospital for an assisted delivery. She signed a consent form for the treatment and indicated that she wanted to take her baby home with her following the procedure. Mrs A believed she had passed her baby's foetus on the first day she was in hospital but was assured that this was not the case by her midwife. When Mrs A was to be discharged, the hospital were unable to locate the tub used for storage of what Mrs A believed to be the remains of her baby.

We took independent advice from a midwife. We found that the midwifes failed to follow the correct procedures in relation to the storage and disposal of pregnancy loss products. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to take adequate steps to address the acknowledged failings in Mrs A's care. Mrs A contacted the hospital following her discharge to discuss her treatment and the location of the tub. After discovering it had been incorrectly disposed of, Mrs A asked for an explanation from the board. Mrs A was told that actions had been taken to prevent a reoccurrence. Mrs A contacted the board's complaint department some weeks later and was told that the incident had not been reported formally or logged as a complaint.

We found that there was no evidence of any actions taken by the board to learn from the incident. We also found that the board had told Mrs A, in their first response to her, that action had been taken and the incident formally logged, which was incorrect. The board then failed to identify this inaccuracy in their second response to Mrs A. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to handle Mrs A's complaint reasonably. We found that the board's handling of the complaint failed to meet the standards expected of them by their complaints handling procedure. We considered that the board did not show an appropriate level of empathy or compassion for Mrs A in their response to the incident and failed to record or respond to the complaint properly. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to provide an appropriate level of care for her, and for failing to handle her complaint appropriately. The apology should meet the standards setout 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:

• Staff are aware of and are implementing the appropriate guidelines in relation to caring for women suffering from a miscarriage.
• Staff are aware of what constitutes a significant incident and how this should be reported and recorded.

In relation to complaints handling, we recommended:

• Staff have the knowledge and skills to identify and register complaints in line with the board's complaint handling procedure.
• The board's complaints handling system should ensure that failings (and good practice) are identified, and that action has been taken to ensure there is learning from complaints to inform service development and improvement.
• The board should use clear and accessible language, sensitive to the patient in cases of miscarriage.

Summary

Mr C complained on behalf of his wife (Mrs A) about a delay in carrying out a CT scan (a scan that creates detailed images of the inside of the body). Mrs A was taken to A&E at Dumfries and Galloway Royal Infirmary and following a CT scan, was diagnosed with having suffered a stroke. Mr C felt that the scan should have been carried out sooner.

We took independent advice from a medical adviser. We found that records of Mrs A's history and examination were inadequate. This meant that we were unable to conclude what Mrs A's condition was at the time of her assessment in A&E and, therefore, if the CT scan was completed within a reasonable time frame. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to document Mrs A's history and examination in line with the relevant guidance. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of relevant standards of documentation in terms of timed entries in clinical notes, documentation of relevant history and examination appropriate to the presenting complaint and documentation and timing of changes in clinical condition, clinical findings and action plan.

Summary

Ms C complained on behalf of her mother (Mrs A) about the care and treatment provided to Mrs A at Borders General Hospital.

After a fall breaking her hip, Mrs A was admitted to the hospital for an operation. At the time of her admission, Mrs A had hearing only in her right ear and staff were advised of this. Mrs A appeared to be making a reasonable recovery after her operation but, the next day, her condition deteriorated and she developed sepsis (a blood infection). She was given two doses of an antibiotic. Shortly afterwards, she developed a bowel obstruction for which she needed an operation and a few days afterwards, she had a heart attack. Mrs A remained in hospital for nearly six weeks and by then she had lost all her hearing. Mrs C complained about Mrs A's care and treatment and said that the antibiotic she had been given had led to her hearing loss. She also complained about poor communication and, amongst other things, not being told of Mrs A's heart attack.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and from a registered nurse. We found that Mrs A's operation had been performed promptly and without any problems but that afterwards, when her temperature and National Early Warning Score (NEWS - an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration) began to rise, no specific action was taken as it should have been. In relation to the antibiotics, Mrs A was very unwell and at risk of dying and, therefore, this risk outweighed the potential harm of giving Mrs  A the antibiotic (which was associated with hearing loss and balance problems after prolonged use). However, we also found that Mrs A was not given a detailed assessment or screened for sepsis. On balance, we upheld this aspect of Ms C's complaint.

In relation to communication, we found that staff had not told the family about Mrs  A's heart attack or made a plan to address or discuss Mrs A's communication needs, with no review of this taking place. We considered that the board's communication was unreasonable and upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for not fully assessing Mrs A; for failing to follow guidance; and for the communications failures. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Patients whose National Early Warning Scores trigger action should be appropriately assessed, including screening for sepsis and delirium.
• Patients and their carers should receive appropriate information about their condition in a way that suits their needs.

Summary

Mr C complained to us about two periods when his brother (Mr A) was admitted to University Hospital Crosshouse. During these admissions, legislation contained in the Adults with Incapacity (Scotland) Act 2000 was utilised by the clinical team as they considered Mr A unable to consent or make decisions on treatment. Mr C complained that the Adults with Incapacity legislation was not used appropriately and that its use was not communicated reasonably to Mr A and his family. In addition to this, Mr C complained about the general level of care and treatment provided during Mr A's admissions.

We took independent advice from an adviser who is a registered medical practitioner with a background in psychiatry. We found that, given Mr A's circumstances during his admissions, the use of Adults with Incapacity legislation was reasonable. In addition to this, we did not identify any concerns about the general level of care provided, although we acknowledged that Mr A's experience may have differed from the information contained in the relevant documentation.

However, we identified shortcomings in relations to the recording and documentation of the use of Adults with Incapacity legislation. In addition to this, there was evidence of gaps in understanding of the Adults with Incapacity Act on a practical level, with factually incorrect information being provided on at least one occassion. Therefore, although it may have been appropriate to utilise Adults with Incapacity legislation, we concluded that there were service failings relating to the understanding of the legislation, the documentation of its use and the resulting communication with Mr A and his family. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for any distress caused due to any lack of understanding of Adults with Incapacity legislation and communication around its use in practice.

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

• Ensure that all relevant staff have an appropriate level of understanding of Adults with Incapacity legislation and its use in practice.

Summary

Ms C complained that the university failed to provide reasonable supervision and monitoring during her full-time PhD course. Ms C withdrew from her course after she had been advised, during the thesis drafting stage, that she would not meet the standard required for a PhD. Ms C stated that the university school involved failed to adhere to a framework which had been produced by the university to ensure a student's progress was monitored. We found that the framework produced by the university could be altered by a school, however, it was intended to ensure a structure was in place for monitoring and documenting progress to ensure consistency. We found that the school did not appear to have a structured approach to supervision and there was a lack of information regarding supervision in the early years of Ms C's course. We upheld this aspect of Ms C's complaint.

Ms C also complained that the university failed to reasonably follow their complaints process. We found that there was not a clear distinction between the university's complaints procedure and their academic appeals procedure. The university also failed to clarify that a meeting to be held was a formal meeting where the complaint would be decided. Ms C's understanding was that this was not a formal meeting and that it was not the final stage for a decision. We also found that the university failed to send documentation with their decision including a minute of the meeting. We upheld this aspect of Ms C's complaint but noted that the university had apologised for this failing and had taken steps to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to put in place a framework for assessment to monitor and document her progress which met the requirements set out in the Postgraduate Structured Management Framework for a 36 month full-time PhD programme. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• A system of assessing and documenting the progress of students in accordance with the requirements set out in the Postgraduate Structured Management Framework for a 36 month full-time PhD programme should be in place.

In relation to complaints handling, we recommended:

• Information provided to students should make clear the distinction between the complaints procedure and the appeals procedure. Communication should indicate the formal process to be followed under the complaints procedure at the outset.

Summary

Mrs C submitted a request to withdraw her children from primary school with the intention of home educating them. Around two weeks after Mrs C submitted her request, an incident occurred with one of her children and a playground assistant which Mrs C reported to the police. Following this, a concern was raised about Mrs C's wish to home educate her children. A referral was made to the Children's Reporter (CR) and as a result, consent to withdraw the children from the school roll was withheld for some six months. The CR concluded that grounds for referral were not met and consent to withdraw the children from school to home educate them was eventually granted.

Mrs C complained that the depute head teacher failed to follow the appropriate policy and procedures in respect of the recording of physical intervention, after the incident involving the playground assistant. The council's policy on physical intervention states that this should be used only as a last resort when all other strategies have been exhausted. It may be used to de-escalate or prevent a violent or potentially violent situation but must not be used to enforce discipline or compliance. We found that the use of physical intervention was not justified in terms of the policy, and the council should have recorded the incident. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the referral to the CR. She was referred on care and protection grounds, namely that her children were absent from school without reasonable excuse. Mrs C said that the council pursued non-attendance even though national guidance states that in most cases it would be inappropriate to initiate or pursue non-attendance procedures in respect of a child awaiting consent to be withdrawn from school. It was unclear from the evidence whether the referral to the CR came from police or the council (as both were involved), but there was evidence that the council encouraged the police to make a referral on the grounds of the children being absent from school without reasonable excuse, despite what the guidance said in this regard. The council were aware of Mrs C's reasons for keeping the children away from school after the incident with the playground assistant. We considered that the council's referral to the CR (or their involvement in the referral) was unreasonable given that it was made in the knowledge that Mrs C had a legitimate reason for the children not attending school. 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 failing to follow their policy in respect of the use of physical intervention, and in particular for failing to record the incident. The apology should meet the standards set out in the SPSO's Guidance on Apology https://www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mrs C for their role in the referral to the CR, given she had a reasonable excuse for the children not attending school because she intended to home educate them, and there were no child protection concerns. The apology should meet the standards set out in the SPSO's Guidance on Apology https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff at the school should understand the policy and know reporting requirements in relation to the use of physical intervention and restraint.
• The council should have a working knowledge of the terms of their policy in relation to home education. They should be clear about the procedures in place for sharing information about families.