Upheld, recommendations

Summary

Mr C complained that the partnership were incorrectly managing his son's direct payment account, as it had fallen into financial deficit.

We found that it was clear from the financial information that Mr C had taken on additional care services, and that this had led to the deficit in the account. However, Mr C had written to the partnership at the time he took on the additional services, and he had continued to provide the necessary financial information to the partnership. Had this information been acted on, the issue would have been identified. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to review and monitor the direct payment account appropriately.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:

• Review the outstanding invoices due and, in light of the failings identified here, meet the liability for the amount due.
• Carry out a review of internal processes to ensure that if new or additional care provisions are being included in financial returns that referrals made to the duty social worker are checked against the user's care/support plan.

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, who works for an advocacy and support agency, complained on behalf of her client (Ms A) about the partnership's handling of Ms A's financial contribution towards her care package. Ms A had received an invoice for unpaid arrears and said that she was never informed that she had to make a financial contribution, and that she had not received any previous invoice before she was notified of the arrears.

We took independent advice from a social worker. We found that Ms A was provided with clear information about her requirement to make a financial contribution towards her care package. However, when difficulties in making those payments became apparent, we considered that the partnership did not take adequate proactive action to support Ms A to manage her finances. As a result, Ms A found herself in substantial debt. We upheld Ms C's complaint and made a number of recommendations. As a result of our recommendations, the partnership exercised their discretion and waived part of Ms A's accrued care charges.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for causing unnecessary stress and for the lack of clarity about the different mechanisms for financial recovery. 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 accordance with their powers as stipulated in the relevant guidance, the partnership should review Ms A's debt and consider whether any reduction is appropriate in light of the failings identified in this investigation.

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

• Give consideration to how they will ensure that there are sufficient safeguards in place to prevent and address difficulties with client debt.
• Review how information about care charges and debts is communicated to clients.

Summary

Mrs C complained on behalf of her father (Mr A) that the ambulance service unreasonably failed to dispatch an emergency ambulance. Mr A collapsed at work with a stroke and two calls were made for an ambulance, which took 50  minutes to arrive. Mrs C felt that the call handler who took the first call had not established sufficient information to determine whether Mr A was conscious or not, and that this affected the priority status of the ambulance response.

We took independent advice from a paramedic. We found that both phone calls were graded appropriately in view of the questions asked by the call handlers. However, in the first call it was not clearly established whether Mr A was conscious or not. Good practice would have been for the first call handler to have questioned the caller in more detail, which would have established an accurate consciousness level and may have affected the grading of the ambulance response. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for failing to fully establish from the call maker whether Mr A was conscious or not. 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:

• The first call taker should ensure that, when talking to callers, they obtain accurate information about the condition of the patient so that an appropriate response level can be activated.

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 length of time that her mother (Mrs A) had to wait for an ambulance.

We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs A be transported to hospital within two hours, and that this was not a request for an emergency 999 response. However, we found that, if a request to be transported goes beyond the agreed timescale, then ambulance service call handlers will carry out urgent welfare call backs to check whether the patient's condition has deteriorated. Where the call handler identifies that the patient's condition has worsened, they should upgrade the call to an emergency response and process it through the medical priority dispatch system. We found that during the first welfare call back Mrs A was reported to be struggling to breath and that during the second welfare call back she had reportedly stopped taking sips of water. We considered that there were failures to appropriately explore possible deteriorations in Mrs A's condition during the first and second welfare call backs. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that possible deterioration in Mrs A's condition were not appropriately explored during the first and second welfare call backs. 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:

• Where there is an indication of a patient's condition deteriorating this should be processed appropriately using the medical priority dispatch system.

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received at Ninewells Hospital after he attended with painless jaundice (a  condition with yellowing of the skin or whites of the eyes). Mr A was later diagnosed with pancreatic cancer. Mrs C considered that the board had not taken appropriate action in terms of treating his symptoms as a red flag for cancer, carrying out appropriate investigations, diagnosing the primary source of cancer, acting on problems with a stent that had been inserted to drain a bile duct blockage, decision-making around surgical treatment and prescription of a medication to help digestion.

We took independent advice from a consultant hepatologist and gastroenterologist (a specialist in the study of the esophagus, stomach, small and large intestines, pancreas, gallbladder, and liver). We found that the initial action taken to investigate Mr A was reasonable and that appropriate tests for his presentation had been carried out. We found that the primary source of cancer had been appropriately diagnosed within a reasonable timeframe and that the action taken in relation to Mr A's stent was appropriate.

We found that surgical decision-making was also reasonable as, although it was initially thought that an operation could be carried out to remove the cancer, subsequent scans showed this treatment would have caused significant harm to Mr A with no benefit. However, we found failings in the prescription of Creon (a  medication that replaces pancreatic enzymes which help digest food) and also prescription of appropriate medication to treat itching caused by bile duct blockage. We noted that Creon could and should have been prescribed earlier and that the types of medication prescribed to treat Mr A's itching are known not to generally improve itching associated with bile duct blockages. We found that Mr A could have been made more comfortable with a different approach. Overall, we considered that the care and treatment Mr A received was unreasonable and upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to prescribe Mr A with Creon, and more appropriate medication to treat the itching associated with bile blockage, earlier. 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:

• Creon and appropriate medication to treat the itching associated with bile blockage should be prescribed when the symptoms are apparent.

Summary

Mr C complained that there was a delay in him receiving medication at St John's hospital when he was admitted after having seizures during the night.

We took independent advice from a hospital doctor. We found that, when Mr C initially arrived in A&E at the hospital, a consultant set out a plan for the medication he was to receive. We found that Mr C was to be prescribed and administered medication in A&E, but that when he was transferred to a ward this had not happened and he ultimately did not receive his medication until he was seen by a doctor the following morning.

We found that Mr C should have received the medication in A&E, and we upheld his complaint. We noted that the delay in receiving the medication did not put Mr  C at high risk of having another seizure, however we considered that this should have been communicated to him. The board said that they had already taken action to ensure that medical staff in A&E were aware of the importance of giving medications to patients when appropriate. We asked for evidence of this.

We also noted that in their complaints responses the board issued inconsistent accounts of what staff were aware of, and when they were aware of it, on the night of Mr C's admission, and so we made some recommendations regarding this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for issuing unclear accounts of what the medical staff were aware of, and when. To confirm this was because it is not possible to determine exactly what the doctors were aware of, on the evening of Mr C's admission to the following morning, due to a lack of clinical nursing notes. 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:

• Ensure accurate records are kept in the clinical nursing notes regarding what is communicated by the patient and what is communicated to the medical staff.

In relation to complaints handling, we recommended:

• To explain to a complainant when it is not possible to provide a definitive account of events and provide the reason why.

Summary

Mr C complained about the care provided to his wife (Mrs A) when she attended A&E at the Royal Infirmary of Edinburgh. Mrs A presented to the department with severe pain in her shoulder. Shortly after admission Mrs A was given morphine for her pain and was assessed by an emergency medicine consultant.

Mr C raised concern about the delay in triage (a process in which things are ranked in terms of importance or priority), inadequate pain management, and the failure to use a cubicle. The board acknowledged that Mrs A should have been moved to a cubicle after morphine was given and apologised for this. We took independent advice from an emergency medicine adviser. We found the care provided to be reasonable, however, the failure to use a cubicle may have impacted on Mrs A's dignity. We upheld this aspect of Mr C's complaint. As the board had apologised for this failing and taken adequate steps to address this issue, we did not make any further recommendations.

Mr C also raised concern about a letter sent to Mrs A's GP in relation to the admission. We found that the letter contained an inaccuracy and upheld this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to investigate his complaint reasonably. We noted that many aspects of the complaint handling were reasonable, however, we found that the board had not investigated his complaints about hygiene. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the inaccuracy within the letter documenting the admission and for failing to investigate part of Mr 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.

Summary

Mr C complained about two consultations he attended at Edinburgh Dental Institute following a referral from his dental practice relating to temporomandibular disorder (a problem affecting the 'chewing' muscles and the joints between the lower jaw and the base of the skull). In particular, Mr C was unhappy with the assessments carried out and the lack of treatment provided.

We took independent advice from a consultant oral and maxillofacial surgeon (a specialist in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck). They considered that most aspects of the clinical management in the department were reasonable. However, they considered that Mr C's medication history was not recorded adequately at the first consultation. In relation to the second consultation, they were critical that an examination was not performed. We upheld these aspects of Mr C's complaint.

Mr C was also unhappy that a clinic letter relating to one of the consultations contained an error and was sent to the wrong address. We upheld this aspect of Mr C's complaint. However, we noted that the board had apologised to Mr C and identified appropriate action to help prevent the issue reoccurring.

Finally, Mr C was unhappy about the way the board handled his complaint. The board acknowledged that their response was delayed and apologised to Mr C for this. We considered that the board's communication about the delay was poor and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to adequately record his medication history, failing to perform an examination, and the poor communication during the handling of his 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 presenting with pain should have their medication history appropriately recorded within the documentation of the management plan. Consultations should include an examination where this is indicated clinically or because of the particular circumstances of the patient's situation.

In relation to complaints handling, we recommended:

• Where it is not possible to complete an investigation within 20 working days, the person making the complaint should be given an update about the delay and a revised timescale for completion. Communication about revised timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable.

Summary

Mrs C had knee replacement surgery at the Royal Infirmary of Edinburgh. She also underwent manipulation under anaesthetic (MUA - a procedure to try and improve movement) to try and relieve knee stiffness after the operation. Mrs C complained about the board's communication with her following the knee replacement surgery. In particular, she complained that she was not properly informed that, should MUA be unsuccessful, there was a possibility that nothing more could be done for her knee. She also complained that she was not told why she had been sent for a second opinion.

We took independent advice from an orthopaedic consultant (a doctor who specialises in the musculoskeletal system). We found that the majority of the communication with Mrs C had been reasonable, and that the advice she was given about MUA was reasonable. However, we found that consent process for the MUA was unreasonable, and that the communication around the second opinion had been poor. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the communication failings. 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 should receive full and comprehensive information during the consent process and second opinion process.

Summary

Mrs C complained about the care and treatment her late son (Mr A) received when he was admitted to the Western General Hospital. Mr A had duchenne muscular dystrophy (a genetic disorder characterised by progressive muscle degeneration and weakness) and an associated heart condition and was admitted to the hospital with abdominal pain and swelling. He died in the hospital a week after he was admitted.

We took independent advice from a consultant general surgeon and a nurse. We found that it had been reasonable to admit Mr A to a surgical ward. He was examined by a surgical registrar and the on-call medical registrar which was an example of good care. However, we found that there had been a number of failings in the care and treatment provided to Mr A. In particular that:

• he should have been treated by a multi-disciplinary group of consultants, including a cardiologist (a doctor who specialises in the study or treatment of heart diseases and heart abnormalities);

• it was unreasonable for a consultant from the hospital's ventilation service not to take appropriate steps to evaluate Mr A when they were informed of his admission;

• it was unreasonable not to record Mr A's fluid intake/output;

• staff failed to act appropriately on an abnormal CT scan;

• staff unreasonably failed to reconsider the diagnosis of kidney infection;

• it was unreasonable for a junior doctor to propose discharging him;

• communication between general surgery and urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) was poor;

• no moving and handling assessment was carried out when Mr A was admitted to hospital; and

• no equipment was available for the safe movement and transfer of Mr A three days after he was admitted to hospital.

We upheld Mrs C's complaint about the care and treatment provided to Mr A, however, we found that it was highly likely that the outcome would have been the same for Mr A if these failings had not occurred.

Mrs C also complained that the communication with her family had been unreasonable. We found that whilst there was evidence of discussions with the family and of staff responding to their concerns, Mr A had complex needs and the family should have been involved in his care in a planned and collaborative way. There was no evidence of this. We found that there had been a lack of appropriate engagement with the family in the assessment and care planning for Mr A and that the communication with his family had been poor. 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 provide Mr A with reasonable care and treatment in the hospital and for the poor communication with her family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• The board should ensure that appropriate multi-disciplinary management is triggered when a deteriorating adult with duchenne muscular dystrophy is admitted to hospital.
• Patients identified as being at risk should have their fluid intake and output accurately monitored.
• The board should ensure that CT scans are acted on appropriately and that the diagnosis is reconsidered in the light of any new findings.
• Patients should be appropriately reviewed and discussed with a relevant member of staff before discharge is proposed.