Upheld, recommendations

Summary

Mr C attended University Hospital Crosshouse after sustaining a tear in the anterior cruciate ligament (a ligament in the knee) and damaged cartilage (connective tissue). Mr C complained that the board took too long to provide appropriate treatment following a referral from his GP, failed to provide a reasonable standard of treatment and failed to communicate reasonably with him about his condition and treatment.

In relation to the treatment time, we found that the board had breached the treatment time guarantee of 12 weeks and considered that this was unreasonable. We upheld this aspect of Mr C's complaint.

In relation to Mr C's treatment, we took independent advice from a consultant orthopaedic surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system). We found that the original injury Mr  C sustained to the knee appeared to be significant but that he had also sustained further injury to the knee while waiting for surgery. However, no updated scan of Mr C's knee was performed and the first time that Mr C was examined by the surgeon under the anaesthetic was when the situation was found to be more complex. The surgery did not proceed and Mr C required to be referred to another specialist for surgery. We considered that there was a failure to provide Mr C with a reasonable standard of treatment and upheld this aspect of his complaint.

Finally, we found that the board could have been more proactive about communicating with Mr C and should have ensured that their response was mindful of the relevant legislation and guidance. Therefore, we considered that the board failed to communicate reasonably with Mr C and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide him with treatment within a reasonable time, to consider obtaining an updated scan, to examine him prior to the surgery and to reasonably communicate with him about his clinical condition 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:

• Treatment should be provided within the 12 week treatment time guarantee. All staff should understand the legislation and guidance on the waiting time guarantee.
• Patients should receive appropriate and relevant scans and be reviewed/examined as appropriate prior to surgery.
• Identify any training needs to ensure staff fully understand the treatment time legislation and guidance, and its application.

Summary

Mrs C complained about the medical and nursing care and treatment provided to her late mother (Mrs A) at Royal Alexandra Hospital. Mrs A was admitted to the hospital from her nursing home and was treated for a urinary tract infection. She was discharged home, but returned to hospital a few days later. A scan showed that Mrs A had suffered a brain haemorrhage (bleed in the brain) and she was started on end-of-life care. About a week later, nurses noticed bruising on Mrs A's hip, and she was found to have suffered a hip fracture. Mrs A continued on end of life care for about three weeks before she died in hospital.

Mrs C felt that doctors did not treat Mrs A immediately when she first attended hospital, and she was unhappy that staff had instead asked the family what level of treatment they would prefer for Mrs A. Mrs C also felt that Mrs A was discharged too early. Mrs C raised concerns about the hip fracture; querying how this could have happened and why it was not discovered earlier by staff. Finally, Mrs C was concerned that Mrs A was kept on end-of-life care for an extended period of time without fluids or sustenance.

We took independent advice from a consultant in general medicine and from a nurse. We considered that it was appropriate for staff to discuss the level of treatment the family wanted for Mrs A when she was first admitted, and that this did not impact on the promptness or thoroughness of her treatment. We also did not find failings in the end-of-life care.

However, we found that staff had failed to establish Mrs A's normal level of functioning (known as baseline level of health) and therefore failed to adequately investigate her deterioration before discharging her. We found that staff should have done more to find out Mrs A's baseline level of health and that this may have alerted them to the fact that she was not back to normal when she was discharged.

We also found that Mrs A had been discharged without thickened liquids that had been prescribed.

Whilst we noted that the board had apologised for the hip fracture, which had probably occurred in the hospital, we found that they had not investigated the cause of the unexplained fracture at the time it was reported.

We upheld Mrs C's complaints about the medical and nursing care provided to Mrs A.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to establish Mrs A's baseline level of functioning and for failing to adequately investigate her deterioration. Also apologise for discharging Mrs A without the thickened liquids prescribed to her and for failing to promptly investigate the cause of Mrs A's hip fracture. 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:

• Where a patient is unable to communicate, staff should clearly document their normal level of functioning, based on information from their family and/or carers.
• Prescribed dietary products should be provided on discharge or available within a few hours.

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's child attends a school which is just under two miles from home, along a rural road. They receive school transport during the winter months, but not during the period between the Easter holidays and the October break. Mr C did not believe that the route between home and school was suitable for young children to walk. He raised a complaint with the council, requesting that the route be re-assessed. The route assessment report was still outstanding a year later. Mr C complained that the council unreasonably delayed in re-assessing the route and that their complaints handling had been unreasonable.

The council acknowledged that the delays in re-assessing the route were unacceptable and confirmed a number of measures they were taking to improve their service. We upheld this aspect of Mr C's complaint and recommended that the council provide a further apology.

In relation to complaints handling, we considered that there had been confusion among staff about implementing their complaints handling procedure alongside the school transport policy. We found that the council failed to comply with timescales or keep Mr C informed at each stage of the process; instead he had to continually chase them up. We upheld this aspect of Mr C's complaint. However, we noted the wide-reaching improvements implemented by the council as a result of the complaint and asked for evidence of these.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the long delay in reassessing the route, and for the poor complaints handling and general level of customer service, including a recognition of the impact of all of this on Mr C. The apology should meet the standard set out in the SPSO’s guidance on apology which can be found at www.spso.org.uk/leaflets-and-guidance.

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

Summary

Mrs C complained that the council failed to deal with her complaint in line with their procedures and that they failed to address her concerns about the school place allocations policy. The council had responded to and upheld a number of her concerns, agreeing to conduct a review of their policies as a result. However, they had told her that they could not respond to legal concerns under their complaints procedure, nor could they consider complaints that amounted to disagreement with policy. Mrs C was unhappy with this response and brought her complaint to us.

We found that the council's complaints handling procedure (CHP) was not in line with the SPSO's model CHP for local authorities, which they have an obligation to ensure. This amounted to their CHP stating that disagreement with policy would not be considered through the complaints process, when the model CHP intends that these complaints, and legal complaints, should both be able to be responded to through the process. This had resulted in the council failing to respond appropriately to Mrs C's concerns. Therefore, we upheld both of her complaints.

Recommendations

What we asked the organisation to do in this case:

• The council should ensure that Mrs C's concerns have been fully addressed and that she has received justification for their final position, with reference to the legislation in question.

In relation to complaints handling, we recommended:

• The council's CHP should not contradict the model 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

Mr C complained about the council's handling of a report of statutory nuisance under the Environmental Protection Act 1990 (the EPA), which he made due to noise coming from a council owned car park adjacent to his home. The council had told him that they did not consider that the nature of the behaviour fell under the remit of the EPA. Mr C was not satisfied with the explanation provided for this and brought his complaint to us.

We took independent advice from an environmental health adviser. They considered that the council's position was unreasonable, confirming that there was a statutory duty to investigate any complaint of statutory nuisance, decide whether a statutory nuisance was occurring and, if it was, serve an abatement notice. Therefore, we upheld Mr C's complaint. However, we noted that the council have now informally investigated the noise report.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to adopt or explain a reasonable interpretation of the EPA in relation to his reports of noise. 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 council should accept that they must investigate any complaint of statutory nuisance to establish whether a nuisance exists.

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, an advocacy worker, made a complaint to the partnership on behalf of Mrs B, regarding the care and treatment provided to Mrs B's mother (Mrs A). Mrs A suffers from dementia and was an in-patient at Stobhill Hospital. Mrs B was concerned about the nursing care provided to Mrs A, in particular with regards to management of Mrs A's incontinence, use of restraint, and an incident which resulted in Mrs A breaking her hip. Mrs B also raised concerns that when Mrs A was moved to Glasgow Royal Infirmary for treatment of her broken hip, there were failings in nursing care. In particular Mrs B was concerned that Mrs A was not receiving her medication due to staff failing to administer it covertly (mixed in food).

We took independent advice from a mental health nurse and a general nurse. We found that the management of Mrs A's incontinence had been reasonable, and that there was no evidence to suggest that the incident in which Mrs A broke her hip could have been avoided or that this was due to an unreasonable level of care. However, we found that the relevant policy in relation to restraint was out of date. Therefore, we considered the nursing care at Stobhill Hospital to be unreasonable and upheld this aspect of Ms C's complaint.

In relation to nursing care in Glasgow Royal Infirmary, we found that there was a failure to follow the covert medication guidance, which was, in any case, out of date. We also found that there was a lack of adequate care planning taking Mrs A's dementia into account, and in particular a lack of multi-disciplinary planning involving Mrs B and an appropriate level of specialist input, which may have resulted in poor and inconsistent care. We also found that there was a lack of pressure ulcer care planning. Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained about the level of communication from the partnership with Mrs B in regards to Mrs A's care and treatment. We found that whilst there was communication from staff at both hospitals, there was no documentation regarding Mrs B's preferences for frequency of communication which would have been helpful given her role as welfare guardian. We also found that there was a failure to complete a 'Getting to Know Me' document (a document which aims to give hospital staff a better understanding of patients with dementia) for Mrs A. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to provide reasonable nursing care and treatment to Mrs A at Stobhill Hospital and Glasgow Royal Infirmary, and for failing to communicate reasonably with Mrs B with regards to Mrs 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:

• The policy on Management of Violence and Aggression should be up to date.
• The Covert Medication Policy should be up to date. Patients who require to receive medication covertly should be cared for in line with the partnership’s Covert Medication Policy and pathway. When medication is missed the potential impact and management of this should be assessed.
• Patients with dementia should have a care plan which records their care needs, and where appropriate involves the multidisciplinary team, family/representatives, and specialist input.
• Pressure ulcer risks should be assessed and managed appropriately.
• ‘Getting to Know Me’ documents should be completed for patients with dementia.

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 provided by the ambulance crew who attended to her husband (Mr A). Mrs C had called an ambulance in the early hours of the morning as her husband was unwell. The crew examined Mr A and told Mrs C that they were not going to take Mr A to hospital, but that she should contact her GP for a home visit when the medical practice opened later that morning. A GP made a home visit and found Mr A to be disorientated and confused, which had been mentioned by Mrs C in her phone call to the ambulance service. The GP arranged for Mr A to be taken to hospital for further assessment and it was later diagnosed that he had suffered a stroke. Mrs C felt Mr A should have been taken to hospital by the ambulance crew.

We took independent advice from a clinician involved in the training of paramedics and concluded that the ambulance crew had failed to adequately record Mr A's symptoms and that he should have been transported to hospital for further clinical assessment. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failure to adequately record Mr A’s symptoms and for failing to transport him to hospital for further assessment and investigations.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 ambulance crew should be competent to adequately record the patient’s full symptoms and be aware of the need to transport patients to hospital for further assessment.

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

Summary

Mr C complained about the way in which the ambulance service handled him after he had a seizure and fell at home, injuring his lower back. Mr C was concerned about the lack of assistance he received from the ambulance crew before they took steps to immobilise his spine and transfer him to hospital. It was later established that Mr C had sustained two fractures of his spine.

We took independent advice from a consultant in emergency medicine. Given that there had been restricted space in the room that Mr C had fallen, together with a number of factors that made it unlikely that he had sustained such fractures, we considered that it was reasonable of the ambulance crew to have provided spinal immobilisation in an area with greater room to do so. However, we noted that there was no evidence of a clinical assessment of Mr C's back and neurological function, nor evidence of a risk assessment prior to the decision to move Mr C. We considered that the assessment of Mr C was unreasonable and upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of clinical assessment of his back and lower limb neurological function. 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:

• Where a patient has potentially sustained a spinal injury staff should carry out a full clinical assessment and risk assessment prior to making decisions about moving and handling the patient. The assessments should also be clearly documented.

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

Miss C complained about the care and treatment provided to her by the board. She complained that the board did not identify that she had an anal fissure (cut or tear in the tissue inside the anus) during an examination under anaesthetic. She also complained about the length of time she had to wait for that examination.

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that it was reasonable that the board did not identify an anal fissure because it was in remission at the time of Miss C's examination under anaesthetic. However, we found that there was a delay in Miss C receiving the examination and that this exceeded the national waiting time standards. We considered that this was unreasonable given the amount of pain she was experiencing. We upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the amount of time she had to wait to receive an examination under anaesthetic. 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 with a suspected anal fissure should be treated within national wait time standards and the board should consider mechanisms to allow patients with severe anal pain to be seen as soon as possible. The board should consider advising patients in a timely manner that they may not be seen within waiting time targets.

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

Summary

Mrs C complained on behalf of her adult son (Mr A) about the care he received when he presented to the emergency department at St John's Hospital. Mr A has autism (a developmental disability that affects how a person communicates with, and relates to, other people) and a learning disability and attended A&E after suffering a dissociative episode (disruption in aspects of consciousness).

We took independent advice from an emergency medicine consultant. The adviser noted that the board failed to meet contemporary best practice when taking the decision to perform a sternal rub (rubbing knuckles on the sternum as an act of stimulation); however, we did not conclude that this action was unreasonable. We found that, in one instance, staff did not communicate reasonably with Mr A. We also noted that the emergency department team did not meet with Mrs C after she made a complaint, which showed a lack of supportive partnership working. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not responding to her concerns in a way that reflected partnership working. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance . Reconsider their decision not to meet with Mrs C and Mr A. The board should inform Mrs C of whether they are prepared to offer a meeting or if an alternative arrangement to effect partnership working would be more suitable.

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

• Staff should recognise that patients with autism and learning disabilities might find the emergency department distressing and this may result in challenging behaviour.

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.