Upheld, recommendations

Summary

C, an advocacy worker, complained on behalf of the family of A, about a failure to appropriately investigate A’s symptoms, and a consequent delay in diagnosing and treating their cancer.

We took independent medical advice from a radiology consultant (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), an Ear, Nose and Throat (ENT) consultant and a general medical consultant. We found that the initial scans A received were reported reasonably and did not show any malignancy. When A’s GP later referred them to ENT, we noted that consideration should have been given to upgrading this to urgent. It remained routine and A was not seen until nine weeks after the referral, at which point their cancer was diagnosed.

In the meantime, A had been admitted to hospital under the care of the general medical team. We found that the medical team did not place sufficient emphasis on A’s physical symptoms, which were ‘red flags’ for the possibility of cancer. There was a failure to scan A’s neck, which is where their symptoms were. We also found that A should have been referred to ENT more urgently, preferably as an inpatient. The general medical team wrote to ENT asking for the earlier ENT referral to be expedited, but the letter did not sufficiently emphasise the physical concerns and placed undue emphasis on the likelihood of the problems being of a psychological nature. Had an ENT review been arranged while A was an inpatient, it is likely that their cancer would have been diagnosed at this point.

We concluded that the board failed to reasonably investigate A’s symptoms and upheld the complaint. We noted that an earlier diagnosis around the time A was an inpatient would have been unlikely to have affected the outcome for A. However, we recognised it would have given A and their family more time to come to terms with the diagnosis.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients’ physical symptoms should be thoroughly assessed and they should be appropriately referred for review and scanning/x-ray as required in accordance with their presenting symptoms.
• Referrals to ENT should be appropriately triaged and upgraded as required.

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

Summary

C complained about the nursing care provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided.

We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified significant failings in how A’s ileostomy care needs were provided and significant gaps in documentation. Therefore we upheld this part of C's complaint.

C also complained about the communication with both A and C about A's health and prognosis. We found that prior to A’s decline C was communicated with in a reasonable manner. In relation to the communication with A in the days before their passing, we found that A was experiencing increasing confusion and cognitive impairment throughout their stay in hospital and at times lacked capacity. In light of this, it was unreasonable to inform A of their poor health without C present. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients should be communicated with in a reasonable manner, and, in line with their capacity, with next of kin present for support if necessary.
• Patients should have a person-centred care plan and staff should follow this.
• The care delivered should be captured in appropriate documentation.
• Stoma care is appropriately recorded in the correct area to support correct stoma care being provided in a reasonable manner.

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

Summary

C complained that the board failed to provide C with appropriate treatment for a shoulder fracture. C was admitted to hospital suffering from alcohol related seizures. It became apparent that C had also suffered a shoulder fracture. C was discharged 12 days later with an orthopaedic referral (specialists in the treatment of diseases and injuries of the musculoskeletal system) for the following week. C was then scheduled for surgery to realign the fracture. This was subsequently cancelled. When C was seen again the following week a different consultant determined that C’s fracture had now healed to the extent that surgery was no longer a viable option.

C complained that the shoulder is now misaligned, causing discomfort and a reduced range of motion affecting day-to-day life and their ability to work. C believes that opportunities were missed to prevent this outcome. The board’s response stated that C was initially too unwell for surgery, and that the cancelled procedure was because of an emergency admission that had to be prioritised. They also noted that there was reason to suspect that the injury was older than C had stated upon admission.

We took independent advice from an orthopaedic consultant. We found that there had been some challenges for the board in providing care and treatment to C. However, it had been evident from three days before C was initially discharged that the fracture was healing out of alignment. We also found that there was insufficient evidence on which to conclude that the injury was older than stated. We noted that various opportunities were missed for earlier surgical intervention and that there was a lack of ownership of C’s case from an orthopaedic perspective, contributing to a series of small delays which ultimately led to the window of opportunity for effective surgery passing. This amounted to unreasonable care and treatment. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Discussions about patient care should be documented.
• Upper / lower limb expertise should be obtained promptly where this is appropriate. In addition, where patient care is being transferred, the board should ensure that there is effective communication and that delays are avoided / minimised.

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

Summary

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's spouse (A). A experienced urological symptoms including blood in their urine and a number of infections. After a number of investigations, A was diagnosed with bladder cancer which had spread to their prostate. A died a short time later.

C raised a number of complaints and we agreed to investigate four main concerns: that the board failed to provide a reasonable standard of urological treatment following insertion of a catheter, the delay in diagnosing A’s cancer; poor communication with B and A, and A’s poorly managed discharge from hospital.

We took independent advice from a consultant urologist.

C raised concerns that A’s catheter had to be refitted a number of times, which was difficult to do and caused A pain and discomfort. The board explained that a catheter is commonly fitted after surgery and a permanent catheter was fitted due to A’s past urology history and difficulty in emptying their bladder. We found that whilst it was reasonable to insert a catheter, the reasoning behind the decision was poorly documented and that as A required a number of emergency admissions for catheter related issues, the board should have considered an emergency cystoscopy (a procedure that uses a tube to examine the bladder and the urethra) and TURP (transurethral resection of the prostate) and they failed to do this.

Whilst it is agreed that A’s case was complex and a number of investigations were required, we found that there was a delay in arranging a diagnostic cystoscopy following an emergency admission, a breach of the waiting time target for cancer referrals and a failure to recognise the significance of paraaortic lymphadenopathy (lymph nodes of an abnormal size) which contributed to the delay in diagnosis of A’s cancer. We accepted that had this delay been avoided, A’s outcome likely would have been the same, although their quality of life would have been improved.

With regards to communication, we did not identify any issue with the volume or frequency of communication with A. However we concluded that important medical details were overlooked or not explained clearly, such as A’s urological diagnosis and overall management plans.

Our investigation also concluded that whilst it was appropriate to discharge A home due to their condition being manageable with pain relief and antibiotics, there was a failure to ensure adequate pain relief would be available to A.

We upheld all four complaints and made appropriate recommendations for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That A’s case be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A’s diagnosis and ways of ensuring similar delays do not affect future patients.
• That the board review the record keeping in A’s case and take steps to ensure their junior doctors and trainees are receiving adequate training in good medical record keeping and that senior clinicians are reminded of their responsibility to maintain sufficiently detailed records of discussions with patients and relatives.
• That the senior staff involved in A’s care be asked to reflect on the way that bad news was delivered on this occasion, and in general, with a view to ensuring they do so in as inclusive and compassionate a way as possible and with reference to the MDU guidance on breaking bad news.

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

Summary

C complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate.

C complained about the care that they received from the board during two hospital admissions. In particular, that staff were unprofessional and unempathetic and became impatient and abrupt when C was unable to do as staff asked.

We took independent advice from a senior nurse. We found that there was a lack of communication and understanding of C’s cognitive impairment which resulted in staff not fully understanding the issues C was dealing with on a daily basis and the challenges their diagnosis presents. There was also a lack of appropriate care planning and a failure to complete all documentation and risk assessments. This led to a failure to provide reasonable emotional and psychological care to C whilst an inpatient, a poor patient experience for C and anxiety over future hospital care. Therefore, we upheld C's complaint.

In addition, we also found that the board’s response to C’s complaint was poor and did not demonstrate the learning or improvement required.

Recommendations

What we asked the organisation to do in this case:

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

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

• Documentation and communications regarding care needs should be highlighted at admission, with all relevant risk assessments completed reflecting accurate assessment and planning of care needs. Care plans should be person-centred to incorporate patients who have a cognitive impairment.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures (www.spso.org.uk/the-model-complaints-handling-procedures). The board should fully investigate and address the issues raised and appropriately identify and action learning.

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

Summary

C complained that social work did not adequately safeguard their child (A) when they disclosed that they had been a victim of assault. C also complained that they were not informed of the incident. The council considered that appropriate support had been offered to A.

We took independent advice from a social work adviser. We reviewed the relevant case records and the council’s child protection procedures. We found that the council failed to meet their obligations and take the appropriate action in response to the disclosures made by A. We found that there was sufficient concern about A’s ability to maintain their wellbeing and that social work should have instigated their child protection procedures. We also found that there was insufficient recording within the case records of a clear plan and rationale to explain decision making. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to meet their obligations and correctly apply their child protection procedures in response to the disclosure made by A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• Case records should include details of discussions held with relevant persons, rationale for any decision making, and evidence of risk assessments, where appropriate.
• Staff should be familiar with the requirements of the council’s child protection procedures and have a clear understanding of when an Inter-agency Referral Discussion should be held.

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

Summary

C complained about the council’s handling of a planning application. C’s next door neighbour made a retrospective application for planning permission for the erection of a garden room/store and timber fencing to the boundary at the rear of the property. This followed an earlier enforcement enquiry in respect of the garden room structure being erected without the necessary permission in place.

C objected to the planning application through a solicitor on the basis that it constituted overdevelopment and would adversely impact neighbours’ residential amenity and did not contribute towards quality place making. Planning permission was granted with no conditions attached.

We took independent advice from a planning specialist. We were satisfied that the assessment of the impact of the fence was an issue of discretion and that carrying out site visits and allowing additional comments/objections to the planning application were matters of planning judgement. Whilst we found that the council did reach the right planning decision, we considered that there had been a lack of clarity and explanation and that the council’s calculations in relation to the coverage of rear curtilage in the Report of Handling were ambiguous and are not in line with the relevant guidance. On balance, we upheld the complaint.

Recommendations

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

• Case officers should be aware of how to measure curtilage areas and calculate the proportion proposed to be built upon. The calculation should be clearly set out and a record made.

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

Summary

C complained about the health and social care partnership’s (HSCP) investigation of a medicine protocol breach identified at their relatives (A) care home in the week before A's death. A social worker investigated the breach in response to an Adult Support and Protection (ASP) notice raised by the care home, and determined that no further action was required. Separately, the Care Inspectorate had investigated other concerns raised by C about the care and treatment provided to A, including the medicine protocol breach. The Care Inspectorate’s investigation identified failings and made recommendations for improvement. In light of this, C contested the partnership’s position, indicating their view that the investigation was faulty, particularly noting the outcome of the Care Inspectorate’s investigation of the same matter.

C received a stage two complaint response letter from the partnership. We considered the response had not fully considered C’s concerns, therefore, we asked the partnership to provide a further response to C’s complaint. C remained dissatisfied with the partnership’s second response.

We took independent advice from a social work adviser. We found that the partnership had a duty to investigate the concerns raised in keeping with ASP legislation. We noted that this matter had been investigated by a single social worker. However, we found that the Care Inspectorate were better placed to investigate the matter in keeping with the Health and Social Care Standards, with the partnership’s role being to liaise with the Care Inspectorate and the care home regarding the outcome and recommendations. While the social worker’s report was in itself reasonable for an inquiry, we found that it was better suited to be used in collaboration with the other relevant agencies. We upheld the complaint.

We also upheld a complaint about complaint handling, noting that C had not been made aware that their concerns were being managed in line with the complaint handling procedure, that the matters to be investigated had not been confirmed at the start of the process and that the complaint responses did not fully address C’s concerns.

Recommendations

What we asked the organisation to do in this case:

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

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

• The partnership should reflect on this decision, particularly taking into account the professional judgement and the decision-making process applied in this case, in reference to the guidance and how this is interpreted in practice.

In relation to complaints handling, we recommended:

• The partnership should ensure complaints are correctly identified and processed in accordance with their complaints handling procedure. Responses to complaints should be clear and answer the points of concern raised.

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

Summary

C complained about the ophthalmology treatment (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) that they were provided by the board. They were referred by a consultant (Doctor 1) for a second opinion from a corneal specialist. C complained that they should have been seen by a consultant (Doctor 2) but were instead treated by a junior doctor (Doctor 3). Additionally, C complained about the treatment provided by Doctor 3 and the decision to discharge them from the ophthalmology service.

We took independent advice from a consultant in ophthalmology. We found that it was clear that Doctor 1 intended a specialist to examine C and that this did not happen. Although it may have been reasonable for C to have been seen by a junior doctor in clinic, there should have been clinical oversight by Doctor 2, with direct input to C’s management plan. We found that it would have been good practice for the outcome of the consultation to be reported back to Doctor 1, copying the letter to the GP and C. Instead, the outcome was only reported to C’s GP. We upheld this complaint. We also found that Doctor 3 should have tested C’s eye pressure before prescribing fluorometholone (a mild steroid). We upheld this aspect of C’s complaint. Finally, we also found it was unreasonable for the board to discharge C from their ophthalmology service, when Doctor 1 had agreed to follow-up in one year. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings our investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• When apologising to C, the board should address their treatment plan and communications in relation to their discharge.
• The board should offer C a further consultation with Doctor 1, given they had agreed to a follow-up consultation with C.

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

• Clinical staff ensure that they write back to the referring clinician, copying to the GP and patient.
• Eye pressure is tested, in accordance with good clinical practice, prior to FML being prescribed.
• Where a tertiary consultant to consultant referral is made, the consultant should be aware that the case is there for their specialist opinion and provide some direct input to their management plan.
• Where referrals are made for a second opinion, the patient is discharged back to the referring clinician.

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

Summary

C complained that the practice had prescribed them with Hormone Replacement Therapy (HRT) for a period of approximately four months despite knowing that they were trying to conceive. C said that they had subsequently attended a fertility clinic and were advised by a specialist that HRT would have a negative impact on their fertility. The practice identified learning and improvement from C’s complaint. They apologised to C for the frustration and distress caused to them by their experience.

We took independent advice from a GP adviser. We found that it was unclear from the medical records if the prescription of HRT was fully discussed with C to ensure that they understood the implications on their fertility and general health. We found that it was unreasonable for the practice to have prescribed C with HRT in the absence of their clear informed decision. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the prescription of HRT in the absence of their clear informed decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.