Upheld, recommendations

Summary

C complained about the service provided in respect of their grandchild (A). C complained that A was not being provided with a stable home environment by their parent (B). C was concerned about the condition of B’s home and whether A and their siblings were being adequately supervised and kept safe. C also expressed concerns over other adults in B’s home.

C said that the partnership did not take their concerns seriously and had failed to ensure A’s health and wellbeing. This included whether sufficient home visits took place, and the decision not to initiate child protection proceedings, or make a referral to the Scottish Children’s Reporter (SCRA). C also raised concerns about social work documentation and processes relating to Interagency Referral Discussions (IRD) and Child’s Plans.

We took independent advice from a social worker. We found that the partnership’s explanations and assurances to C, with respect to the number and nature of home visits, did not match the available records and that there had been a failure to carry out robust and timely assessments of B’s home. Where home visits did take place, there was a lack of evidence that key concerns related to the condition of specific areas of the home were addressed. Regarding the referral to the SCRA, we found that while the IRD stated that ongoing assessment would determine if a SCRA referral was required, there was no indication of the parameters of the ongoing assessment or what timescales were in place. Furthermore, the IRD did not state by whom, or by when, actions should be completed and lacked clarity regarding roles and responsibilities. Similarly, the Child’s Plan lacked clarity and contained significant omissions. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for these failings. 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 ensure that where they have involvement in relation to concerns raised about the welfare of a child, that relevant documentation is completed and monitored to a reasonable standard.
• Where concerns are raised about the wellbeing of a child, reasonable, timely and robust action should be taken to assess and investigate the situation.

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 care and treatment provided to their late parent (A) by the board. A, who had a history of breast cancer, was admitted to hospital with pain and vomiting. Tests were carried out and A underwent a liver biopsy. Following the biopsy, their condition deteriorated and they died a few days later. C felt that A’s death was premature and was hastened by the actions of the board.

The board said that CT scans showed that A had an abnormal liver and an MRI was requested. This wasn’t completed until eight days later due to high demand. The liver biopsy was undertaken the same day. When A began to deteriorate, an urgent CT scan showed that A was bleeding from an injury to the branch of the cystic artery from the biopsy site. The board said that this is a known complication of a liver biopsy. The bleed was successfully treated but A deteriorated further and died. A had shown signs of potential infection and was commenced on antibiotics. The post-mortem stated that the cause of death was ‘complications of liver biopsy and metastatic breast cancer in liver’, and could not conclude to what extent the infection contributed to A’s death.

We took independent advice from a consultant general and colorectal surgeon. We found that the MRI did not appear to have been reviewed prior to proceeding to biopsy and the breast team were not notified of the CT scan results. We also noted that A was not referred to the breast cancer multidisciplinary team (MDT). We found that antibiotics should ideally have been administered within one hour of deterioration and sepsis considered as a main cause of A’s deterioration. A was also given a cystic artery embolization (a minimally invasive procedure that blocks or closes the blood vessel) and two units of blood despite having a normal blood count and no evidence of significant bleeding. Therefore, we upheld this part of C’s complaint.

C complained about communication with A and A’s family, stating that A was not given sufficient information about their condition or results from tests. A’s family were unaware of test results until after A’s death. We found that communication with A and A’s family was unreasonable and that there had also been an absence of communication with the breast team and MDT, which was a missed opportunity. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to undertake a Significant Adverse Event Review. We found it was unreasonable for the board not to have undertaken a Significant Adverse Event Review. This was a missed opportunity to reflect on A’s care and treatment, and identify learning from these events. We upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment to A, the failure to communicate to a reasonable standard and the failure to undertake a Significant Adverse Event Review. 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:

• Plans for investigations, especially of an invasive nature, should be adequately discussed with the patient, including where there is a suspicion of malignancy.
• Relevant clinical teams should be involved, especially where investigations were initiated prior to admission. Sepsis should be appropriately considered as a reason for deterioration, and wherever possible, antibiotics be administered within an hour of deterioration. Appropriate treatment should be given based on clinical signs and symptoms.
• Significant Adverse Event Review’s should be completed in line with the national framework and the board’s own protocols.

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 reasonable care and treatment to their late parent (A). A became acutely unwell with uncontrollable diarrhoea, severe abdominal pain and vomiting. After visits from both a community nurse and out-of-hours GP, C called for an ambulance. The ambulance crew called ahead to the hospital to have A admitted, as per the board’s alternative admission pathway. As agreed during the call, A was taken to the Acute Medical Unit (AMU) but there was no bed for A on arrival. Initial observations and ECG/bloods were taken but A was found unresponsive a short time later and died of a cardiac arrest.

The board apologised that no bed was available for A. They reviewed A’s case and concluded that the appropriate referral pathway was followed. However, they acknowledged that patients with undifferentiated (undiagnosed) abdominal pain should not be admitted to the AMU.

We took independent advice from a consultant physician in acute and general medicine. We found that the board failed to obtain key information to determine which pathway should be followed. This resulted in A not entering the correct pathway. We found that the board failed to escalate A’s care and treatment in line with relevant guidance and with their own policy. We found that A’s care was compromised by the board’s alternative admission pathway. It is possible that the outcome may have been different had the correct pathway been accessed. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to carry out a Significant Adverse Event Review (SAER) following A’s death. After being notified of our investigation, the board commissioned a SAER. Although we welcomed this, the board did not provide assurance that they have adequate systems in place to identify, investigate and learn from adverse events. The board’s failure to commission a SAER following A’s death did not meet the standards outlined in the relevant guidance, and was unreasonable. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients should be admitted to the correct care pathway on the basis of their presenting symptoms. When accepting patients with undifferentiated gastrointestinal symptoms, local teams should be aware of the presence or absence of abdominal pain. Teams should ensure that they ask this specific question when accepting patients.
• Patients should be managed in line with their presenting symptoms. Observations should be carried out in line with the board’s escalation policy.
• There should be a robust process in place for reviewing all unexpected deaths, and, where appropriate, prompt commissioning of SAERs. Learning from these events should be disseminated and shared across teams in line with national guidance.

In relation to complaints handling, we recommended:

• Complaint investigations and case reviews should respond to all of the main points raised, identify failings where appropriate and take learning from what happened. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 care and treatment provided to their late parent (A). Scans revealed findings that were suggestive of bladder cancer. Over a number of further admissions, A received treatment to resect (remove) a bladder tumour, fit and remove catheters, treat infection and generally manage A’s condition. Eventually, it was decided that A’s condition should be managed palliatively, and A was discharged home.

C complained that the medical and nursing care and treatment A received from the board was unreasonable and that the communication with A and their family was unreasonable.

The board said that A was not medically or psychologically fit for further management of their condition and they were not a candidate for chemotherapy or radiotherapy. A was referred to palliative care once it was identified that they were also not a candidate for surgery. The board said A chose not to share their diagnosis for a number of weeks and were unwilling for discussions to take place with their family.

We took independent clinical advice from a consultant urologist (specialists in he male and female urinary tract, and the male reproductive organs) and a registered nurse. We found that the surgical care was of a reasonable standard and that the board adopted a holistic approach. However there was a failure to detect the bladder tumour when it was initially suspected and a failure to follow up with A about their nephrostomy (a thin tube inserted through the skin directly into the kidney to allow urine to drain into an external drainage bag) and JJ stents (a thin flexible tube placed to help urine flow). We also found that there was a delay in organising an inpatient CT scan, failures in relation to discharge planning and a failure to care for A’s skin and pressure damage.

In relation to communication, we found that the board failed to tell A that there was a suspicion of bladder cancer at an appropriate time and it was unreasonable for the board not to communicate with A’s family when arranging discharge.

We considered that the board failed to provide reasonable care and treatment to A and failed to communicate reasonably with A. Therefore, we upheld these parts of C’s complaint.

C complained that the board failed to handle their complaint reasonably. We found that the board’s investigation and response contained a number of factual inaccuracies, particularly with the accuracy of dates and order of events, and that important information was omitted from the response. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable care and treatment to A, failing to communicate reasonably with A and their family, and failing to provide a reasonable response to C’s complaints. 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:

• Discharge planning should take into account the patient’s ability and motivation to complete required self-care tasks such as catheter and nephrostomy care. Patients should be issued with a copy of the discharge letter where appropriate. When a patient does not live independently family members should be informed of their discharge to ensure there is appropriate care in place.
• There should be nurse specialist support for patients with urological cancers. Nurse specialists should contact the patient within a reasonable timescale. Patients should be assessed to ensure suitability before phone consultations are carried out. Patients should be supported, where possible, when bad news is being communicated to them. Relevant updates should be given to a patient in a timely manner.
• There should be adequate trainee supervision during surgical procedures in keeping with the trainee’s experience. Patients should be informed of investigation findings if they are suspicious of a cancer diagnosis. When there is a suspicion of cancer further investigations should be carried out with due diligence. Relevant findings should be discussed with the patient and recorded in the medical notes.
• A pathway should be in place to ensure that patients with nephrostomies and/or JJ-stent are followed-up in line with best practice time frames.
• Inpatient scans should be carried out within a reasonable time frame.
• Wound charts should be in place for pressure wounds and there should be subsequent weekly assessments. Care rounding should be delivered to the frequency required to prevent pressure damage. Patients should be appropriately moved position to avoid worsening pressure damage.

In relation to complaints handling, we recommended:

• Complaint responses should be factually accurate. Details such as dates and the order of events should be supported by what is recorded in the medical records, and these should be checked for accuracy before the response is issued. Complaint responses should be completed in line with the NHS Model Complaints Handling Procedure.

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 care and treatment that their late parent (A) received while in hospital. A suffered a fall and broke their hip. C complained that A was never provided with a falls monitor despite being assessed as a falls risk. C also said that there was a delay in reporting the fall and having A assessed.

The board apologised to C for the fact that, due to a lack of falls alarms, A had not received one. They explained that additional alarms had been obtained to ensure a sufficient supply on the ward. They also accepted that a ‘top to toe’ examination should have been carried out following A’s fall and that there was a delay in identifying that A had a broken hip. They explained that a full review of A’s fall was underway, and if any learning points were identified, they would be acted upon. In addition, a teaching session had been carried out to ensure best practice was followed at all times. The board provided us with details of the learning points that had been identified as a result of the complaint.

We took independent advice from a registered nurse. We found that there was no evidence that A received timely risk assessments or person-centred care. Although a fall with harm was apparent from A’s misaligned leg, this went unnoticed. Basic assessments, including pain assessment, were not conducted, resulting in a delay in recognising A’s pain. Additionally, wound charts were not completed, and there was a failure to follow policy regarding pressure ulcer prevention, malnutrition, and wound assessment and management. While the board had taken action in response to the complaint, we considered that there were still areas for learning and improvement. Therefore, we upheld C’s complaint.

We also found that the board’s complaint response had not been open, transparent, and accurate. The board had failed to identify a number of failings in A’s care and treatment. Additionally, the board had not provided this office with all relevant information in response to our initial enquiry. A significant number of relevant documents were only made available to us after a follow-up enquiry. We made recommendations to address this.

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 board should ensure that nursing staff are aware of their responsibilities for completing relevant documentation in relation to person centred care planning, risk assessment and wound assessment and that the documentation is to the standard required. The board should ensure that there is a consistency of approach from nursing staff when a patient places themselves on the floor and the board’s guidance on what nursing staff should be doing is followed.
• The standard and content of patient documentation in relation to person centred care planning, risk assessment and wound assessment should comply with all relevant guidance and policies and with best practice.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. They should be accurate in their findings and conclusions, clear, and supported by relevant evidence, such as medical records.

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 care and treatment provided to their late parent (A). A was experiencing shooting back pain, tingling sensations, abdominal swelling, weight loss, poor balance and constipation. A contacted the practice on four occasions with deteriorating symptoms. By the last contact, A was incontinent and unable to mobilise. After some delay, the practice organised (seated) ambulance transport to hospital. A was diagnosed with malignant spinal cord compression (MSCC) caused by metastatic renal cancer. A was paralysed and incontinent until they died a few months later.

C complained that the practice failed to spot red flag symptoms for MSCC and cancer, missed opportunities to send A to hospital earlier and failed to appropriately manage A’s transfer to hospital. C said that when A was discharged from hospital their pain, nutrition, appetite loss and low oxygen levels were not effectively managed. They also complained that a GP inappropriately discussed A’s terminal prognosis and do not attempt cardiopulmonary resuscitation (DNCPR) decision at a home visit.

The practice said that, in previous appointments, they had examined A, conducted blood tests, inquired about symptoms of cord compression, and provided advice on what to do if the condition worsened. They recommended going to the hospital only after symptoms deteriorated. They advised that on discharge, the GP had considered it important to discuss prognosis and DNCPR at the earliest opportunity and had made every effort to do so sensitively. They said that they had adjusted A’s pain medication and referred to palliative care nurses. The practice also said that they had referred to a dietician and it would not be standard practice to check oxygen levels as it would not change the overall palliative care.

We found that it had been unreasonable not to arrange a stretcher transfer to hospital at an earlier date. We also considered that it was unreasonable that changes to pain medication had not been timeously reviewed. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for not referring A to hospital sooner, for not timeously organising appropriate ambulance transport on a stretcher, for not contacting a specialist to expedite review on arrival at hospital, and for not appropriately reviewing A’s pain medication. 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:

• All medical staff employed by the practice are familiar with the referral guidelines for possible malignant back pain and cord compression, such as the West of Scotland Guidance and Recommendations| Spinal metastases and metastatic spinal cord compression | Guidance | NICE.

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 their late partner (A) with reasonable treatment for bladder incontinence. A was admitted to hospital following a fall in which they fractured their hip. A was catheterised after undergoing surgery. C complained that when A’s catheter was removed, they developed a bladder problem, and that hospital staff did nothing to rectify A’s inability to control their bladder or investigate what was causing this. C believed if A’s bladder problem had been addressed they may have made a full recovery. A’s condition deteriorated after discharge and they died within a few weeks.

When the board originally responded to C’s complaint they said that it was documented in the nursing notes that A was incontinent on three occasions. The board said a urine specimen was taken which returned a positive result for a urinary tract infection and A was treated with oral antibiotic medication. The board said that prior to discharge, A was mobilising to the toilet and there was no mention of incontinence thereafter.

C highlighted a number of entries in A’s records which referred to incontinence/use of pads. We asked the board to comment on this, noting this contradicted their position in the complaint response. The board confirmed that if all this information had been considered by the multi-disciplinary team, this may have prompted additional continence support and follow-up being arranged on A’s discharge from hospital. The board confirmed that they were taking forward learning points including an action plan for improvement.

We took independent nursing advice. We found that despite a number of references within the multidisciplinary notes to A’s incontinence, there appeared to have been no attempts to explore this further and to provide appropriate support during A’s admission and/or follow-up after discharge from hospital. Although the board missed an opportunity to address these issues, it was not possible to determine the extent of the impact on A, who had a number of significant health concerns. We upheld C’s complaint and made a recommendation for apology. We considered that the action plan appropriately addressed failings so made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable treatment for A’s incontinence and for failing to appropriately identify concerns about A’s bladder issues in their investigation of C’s complaint. 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.

Summary

C complained about the care and treatment that they received when they attended the board’s urgent care centre with sudden hearing loss in their right ear. C’s hearing loss became permanent and they felt that this could have been avoided.

We took independent advice from a consultant in emergency medicine. We found that the board’s assessment of C was unreasonable. While a clinical assessment was undertaken, a clinical hearing assessment was not, which meant that the cause of C’s acute hearing loss was not ascertained. This could have led to alternate treatment options. The board also failed to provide reasonable advice on what to do if C’s symptoms should continue after five days. The board’s response did not reasonably reflect the records available, and their investigation did not identify the failings in C’s care. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess C’s hearing loss and provide appropriate care and treatment. 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:

• Guidance is available to staff which provides a localised and helpful pathway as to the action to take when a patient presents with sudden hearing loss.
• Practitioners delivering the out-of-hours/primary care emergency centre service have an appropriate level of training to assess patients presenting with sudden acute hearing loss.

In relation to complaints handling, we recommended:

• Responses to complaints are accurate, identify failings when they occur and seek to take learning from what happened to make similar failings less likely to occur.

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 parent (A) in hospital. A had been transferred from another health board for rehabilitation having suffered a stroke. C said that there was infrequent care rounding and that the provision of and monitoring of A’s diet, nutrition and fluid intake was poor. C also complained about communication, catheter care and pain management.

We took independent advice from a nurse. We found that record keeping was not to the standard required in areas such as care rounding, fluid balance and food charts, and pain assessment documentation. The lack of accurate records of A’s nutritional assessment and needs suggested that A’s nutritional intake was not delivered to a reasonable standard and that they were at risk of malnutrition. Additionally, the absence of pain assessments on A’s observation and care rounding charts indicated a failure to properly evaluate A’s pain levels, making it difficult to determine if the pain medication provided was effectively relieving their pain. We determined that there had been a lack of assessment, evaluation, and implementation of A’s care needs and lengthy gaps between care interventions. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• 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:

• Nursing staff should be aware of and achieve the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping. A patient’s pain should be appropriately assessed and documented in their patient records.

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 medical and nursing care and treatment provided to their late parent (A). A was admitted to hospital after repeated falls at home. A’s behaviour changed significantly during their admission which suggested that their mental state was deteriorating. C said that they were not directly informed of this, and that A was not referred to the mental health team. A had also been refusing to eat and began to vomit blood. C was not contacted at this point, and was not informed of A’s deterioration until later that day.

We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A had been prescribed medication, which combined with existing health conditions, should have required additional medication to protect their stomach. This was exacerbated by A’s refusal to eat. We found that nursing records of A’s nutritional intake were not completed. Additionally, A’s mental state was not properly assessed. We also found that the board had told C that they would make a change to improve the electronic prescription system. However, this change was not possible and the board had not informed C of this. We considered that A’s nursing and medical care fell below a reasonable standard and upheld these parts of C’s complaints.

C also complained about the board’s complaint handling. We found that the board’s response to C was inaccurate. 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 failure in medical and nursing care, as well as the complaint handling failures identified in this report. 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 receive the relevant assessments and care planning that reflects their needs. All relevant patient documentation should be completed and recorded in the nursing records in accordance with the NMC Code.
• Patients receiving corticosteroid medication at risk of gastritis or other gastric injury, should receive proton-pump inhibitor (PPI) medication as well.
• Patients should be appropriately assessed when there are changes in their behaviour.
• Person centred care plans should be followed for each patient and weight loss should be recognised and responded to.
• Staff are aware of the importance of prescribing and monitoring a patient’s medication appropriately.
• The board should develop clear guidance to ensure patients with mental health issues can have timely access to nursing staff trained in mental health care.

In relation to complaints handling, we recommended:

• Complaints should be investigated in line with the Model Complaints Handling Procedure. Actions and improvements should only be included in complaint responses when the board is able to carry them out.

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.