Upheld, recommendations

Summary

A firm of solicitors (Firm C), raised a complaint on behalf of their client (Mrs A) that, during an examination under anaesthetic, a consultant had carried out a rectal examination without her knowledge or consent. She only found out about this when she received a copy of her medical records. When Firm C raised concerns about this with the board, they passed the correspondence to the consultant (who no longer worked for the board), who responded to Mrs A directly. The board subsequently accepted the consultant's response as their response to the complaint and did not investigate the complaint through their complaints handling procedure.

We took independent advice from a consultant in obstetrics and gynaecology (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts). We found that it was not routine practice to perform a rectal examination as part of the examination Mrs A was having conducted. The Royal College of Obstetricians and Gynaecologists guidance on Obtaining Valid Consent states that procedures should not fall out-with that which the patient consented to, unless there is an unanticipated emergency. We found that Mrs A should have been aware that a rectal examination was a possibility prior to the procedure and consented as such. In the absence of consent, it was not reasonable for a rectal examination to be carried out. We upheld the complaint.

We also had concerns about the way in which Firm C's concerns had been handled. Firm C had clearly raised a complaint and our view was that the board should have investigated and responded to this in line with their complaints handling procedure. We made recommendations regarding this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for conducting a rectal examination on her without her knowledge or consent and for failing to consider her complaint through the complaints handling procedure. 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:

• Ensure that clinical staff in the Obstetrics and Gynaecology department are aware of the Royal College of Obstetricians and Gynaecologists guidance on Obtaining Valid Consent.
• Consideration should be given to a discussion about consent at the departmental induction for doctors and/or a training session.

In relation to complaints handling, we recommended:

• Complaints handling staff should be aware of the board's complaints handling procedure and how to recognise a complaint.

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 compained about the care and treatment that her husband (Mr A) had received during a number of admissions to Hairmyres Hospital. Mr A had initially been admitted with abdominal pain, and he was found to have a stone in his urinary tract and some thickened loops of small bowel. His pain decreased and, after review by the urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) and general surgeons, he was discharged home.

Mr A was readmitted three weeks later with similar symptoms and required surgery. During his stay he had thromnophlebitis (inflammation of a vein related to a blood clot) in his arm and it was felt that he should have his blood thinned with warfarin (a medication used to thin the blood and prevent blood clots). He was then discharged home, but was readmitted five days later because he had very high Internalised Normalised Ratio (INR - the higher the number, the longer the takes the blood to clot).

Mrs C complained that the board failed to provide reasonable treatment to Mr A.

We took independent advice from a consultant general surgeon. We found that it had been reasonable to discharge Mr A following his first admission. However, when he was readmitted he was prescribed warfarin outside of the guidance for anticoagulation (blood thinning), as thrombophlebitis is not an indication for anticoagulation. The justification for this had not been clearly recorded. We found that, whilst it had not been unreasonable to give Mr A warfarin, the clinical reasons for this should have been clinically documented.

We also found that there was some confusion about the dose of warfarin that Mr A should take at home. We found that Mr A's readmission with high INR could have been avoided by ensuring that his anticoagulation was stable before discharge. We found that the board's anticoagulation guidelines needed to be updated. In addition, we found that a blood sample had gone missing when Mr A was in hospital, and that he had to have this sample retaken. In view of these failings, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failings in relation to the warfarin he received. 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 use of warfarin or similar medication should have clear and acceptable justification and any exception for clinical reasons should be documented and accessible.
• Review the pathway of blood tests to minimise the risk of losing samples.

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 she received at Wishaw General Hospital. Following a heart attack, Mrs C attended the hospital on a number of occasions in the period whilst she waited for heart surgery. She was unhappy with the way the board managed her condition in this period and the way the board coordinated her care.

We took independent advice from an emergency medicine consultant, an acute physician and a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels).

Mrs C firstly raised concern that the board failed to investigate her symptoms and provide her with appropriate treatment. We found that, during the first admission, Mrs C was diagnosed with an acute coronary syndrome (symptoms attributed to obstruction of the coronary arteries). Mrs C also had hyperglycaemia (high blood glucose) but was not prescribed insulin. The adviser noted that tight blood glucose control is important in acute coronary syndrome and considered that the board failed to monitor Mrs C's blood glucose levels appropriately and failed to prescribe insulin. We also concluded that there had been a delay in Mrs C being reviewed by a cardiologist and that a GRACE score (which takes into account a patient's age, heart rate, systolic blood pressure, kidney function, signs of heart failure, as well as other parameters in order to calculate the risk of in hospital death) should have been calculated earlier as this can inform the need for angiography (a type of x-ray used to check the blood vessels). In relation to a later hospital admission, we considered that it was unreasonable for the board to have discharged Mrs C without assessment by a senior physician, in view of her medical history and presenting symptoms. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to coordinate her surgery with another NHS organisation that was involved in her care. The board acknowledged that there was a lack of detail in the documentation of the conversation between their medical staff and the staff from the other organisation. We found a number of points in Mrs C's care where the communication with the other organisation could have been better. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to investigate her complaint reasonably. The board acknowledged that they had not addressed all the issues raised in her complaint letter. We considered that since Mrs C's original complaint spanned two NHS organisations, and the co-ordination and communication involved between each, the board should have worked more closely with the other organisation and issued a single complaint response. 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 reasonable care and treatment; unreasonably discharging her without assessment by a senior physician; failing to coordinate her care with another board reasonably; and not fully responding to her 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:

• Where a patient presents with an acute coronary syndrome and has hyperglycaemia, close monitoring of blood glucose levels should be a routine part of acute coronary syndrome management. Insulin should be prescribed for patients who require insulin and adm
• Patients who have been diagnosed with an acute coronary syndrome should be reviewed by a cardiologist within a reasonable timescale. In line with guidelines, patients should be risk assessed for future adverse cardiovascular events and the timing of coron

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 complained about the care and treatment her late father (Mr A) received at Queen Elizabeth University Hospital. Mr A was admitted to hospital with a broken hip after falling at home and underwent an operation. Ms C complained about both the medical and nursing care Mr A received. The board acknowledged that there was an unreasonable delay in transferring Mr A to the orthopaedics (the specialty of medicine regardingconditions involving the musculoskeletal system) ward and identified failings in nursing care, which they apologised to Ms C for. Ms C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant orthopaedic and trauma surgeon (a specialist in diagnosing and treating a wide range of conditions of the musculoskeletal system) and from a registered nurse. We found that there was no unreasonable delay in carrying out Mr A's hip operation, as he needed treatment for other health issues to ensure he was fit for the operation. However, we considered that there was an unreasonable delay in transferring Mr A to the orthopaedic ward, which the board had accepted. Therefore, we upheld this aspect of Ms C's complaint.

In relation to the nursing care, we found that there was an unreasonable failure to communicate with Mr A's family about the risk of him developing delirium and that there was a delay in obtaining information about his likes/dislikes but we considered that reasonable steps were taken to minimise Mr A's risk of a fall. We also found that there was a failure to transfer all of his belongings with him when he moved to another ward but the board had subsequently found his belongings and returned them to Mr A's family. Finally, we noted that his bowel movements were not monitored and/or recorded appropriately. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to properly monitor and/or record Mr A's bowel movements. 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:

• Nursing staff should appropriately monitor and record patients' bowel movements, particularly after they have an operation.

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 to her late husband (Mr A) at the Queen Elizabeth University Hospital. Mr A had liver cancer and was admitted to hospital to have a procedure to deliver chemotherapy directly into the tumour. This is known as transarterial chemoembolization (TACE). Mr A become unwell following the procedure and died. The cause of death was linked to some of the chemotherapy drug entering the pancreas and part of the bowel, causing them to become damaged. Mrs C complained about the care and treatment Mr A received in relation to this procedure.

We took independent advice from a consultant interventional radiologist (the type of clinician who carries out TACE procedures) and a consultant heptologist (a liver specialist). We found that the treatment Mr A received was reasonable, however, the adviser highlighted concerns that the consent process was inadequate. The complication that Mr A experienced is a rare but recognised risk of the TACE procedure. We found that there was no documentary evidence that the risks of the chemotherapy drug affecting another area of the body or death were appropriately covered during the consent process. Obtaining appropriate informed consent is an important part of a patient's care pathway. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that the consent process did not adequately document the risks of the procedure. 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 be appropriately informed of the risks and benefits of transarterial chemoembolization procedures in line with national guidance on consent.

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 board failed to take appropriate steps for her child's (Child A) plagiocephaly (asymmetry of the skull). Mrs C received several visits at home from the health visitor team following the birth of Child A and raised concerns about the shape of Child A's head when they were three months old. Mrs C later attended her GP and was referred to a paediatrician (a doctor who deals with the medical care of infants, children and young people) who diagnosed them with plagiocephaly. Mrs C considered that if the health visitors had identified problems with head shape sooner, it could have been prevented.

We took independent advice from a health visitor. We found that when the health visitor who visited Mrs C was advised of her concerns, they gave appropriate advice regarding positional changes to maintain Child A's natural head shape. However, no record was taken of the circumference of Child A's head or the shape. Therefore, there was no baseline information and we considered that it would have been reasonable to document this for later comparison. We also noted that there was no recorded plan to review the situation. We found that Mrs C was visited by several members of the same staff team but her concerns had not been shared between staff. It would have been appropriate to share this information to ensure continuity of care. We considered that if these steps had been put in place then Child A may have obtained physiotherapy support sooner. Therefore, we upheld Mrs C complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to follow up on her concerns about Chid A's head shape. 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:

• All members of health visiting teams should have up-to-date guidance on the identification, assessment and management of plagiocephaly in young children.
• There should be a structured approach to care planning so that concerns and plans to review those concerns are documented.
• There should be effective communication within teams where several members of the team are providing care for the same family.
• There should be a review of their compliance with the Universal Health Visiting Pathway and a timeline provided for this review.

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 complained on behalf of her late mother (Mrs A) who was admitted to Aberdeen Royal Infirmary after complaining of severe back pain. On admission to hospital, Mrs A was also suffering from vomiting, constipation and had an infection. Ms C considered Mrs A did not receive reasonable care and treatment during her admission. In particular, that the board should have performed an MRI scan on Mrs A's back as she had previously had surgery for a spinal fracture.

We took independent advice from a consultant in geriatric medicine (specialist in care of the elderly) and a nurse. We found that the actions of staff following Mrs A's admission to treat the cause of her dehydration and to determine why she was unwell and in pain were reasonable. We considered that all the relevant tests had been carried out and action taken by medical staff was reasonable. We also considered that the pain relief medication prescribed for Mrs A during her admission was appropriate. However, we noted that on one occasion Mrs A did not receive a dose of paracetamol when she should have and it was possible she may have suffered an increase in her pain as a result. The adviser noted that Mrs A's pain relief medication was an important part of her treatment. This incident was referred to by the board as an adverse event and was recorded on their Datix system (a system for tracking and reporting incidents). It was also noted that Ms C had not been made aware of this incident at the time. Therefore, we upheld Ms C's complaint.

Ms C also complained that the board did not respond reasonably to her complaint. The board acknowledged that there were factual errors in their complaint correspondence and we considered that they had appropriately apologised to Ms C for this. We found, however, that there was an unreasonable delay by the board in informing Ms C that an adverse event had been recorded and this was compounded by their failure to tell Ms C the specific details of this event, despite her asking for them. We considered that the board had not provided Ms C with a full and reasoned response to her complaint and, therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mrs A with reasonable care. Also apologise for the unreasonable delay in informing Ms C that an adverse event had been recorded on the Datix system, and for not providing her with an appropriate explanation of the adverse event and what, if any, harm had been caused to Mrs A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Identify any training needs to ensure staff fully and appropriately respond to complaints.

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 on behalf of his late wife (Mrs A) about the care and treatment she received at Forth Valley Royal Hospital. Mrs A had been experiencing tingling in her fingers, which continued to worsen. Mr C complained there was an unreasonable delay in carrying out a scan to investigate Mrs A's condition. He also considered that there was an unreasonable delay in giving Mrs A the results of the scan. After Mrs A was referred for surgery, her mobility declined. Mr C felt that, with earlier surgery, she may have been walking normally.

We took independent medical advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mrs A was appropriately referred for an urgent scan and that it was carried out within a reasonable timescale. However, we considered that there was a delay in reporting the results and in giving Mrs A the results, which was unreasonable as there were significant clinical findings that required urgent surgical intervention. The adviser considered that earlier surgery was likely to have improved Mrs A's outcome and mobility. However, they explained that a good outcome was not guaranteed, as her condition was degenerate and it was unlikely she could have been walking normally. In light of these delays identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in reporting Mrs A's scan and in telling her the results. 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:

• Urgent scans should be reported promptly.
• A process should be in place so that significant findings in scans and x-rays are immediately flagged up to the referring clinician (this could, for example, be through a generic phone number or email address that is checked and acted on daily).

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 complained about the care and treatment she received at Borders General Hospital. Ms C suffered from lower abdominal pain and appeared to have diverticular disease (disease of the colon). Ms C attended the emergency department at hospital on six occasions over a number of months. She complained that over this period of time the board did not treat her reasonably and failed to carry out suitable investigations. As a consequence, she said her diagnosis was delayed and her treatment options were reduced. Ms C also complained about the actions of nursing staff and about the way the board dealt with her complaint.

We took independent advice from a consultant general and colorectal surgeon (a specialist in the medical and surgical treatment of conditions that affect the lower digestive tract) and from a registered nurse. We found that Ms C's initial investigations had been satisfactory. However, she continued to present with similar symptoms and persistent pain which, therefore, should have indicated that her diverticular disease had progressed and she should have received a scan earlier. Had this been the case, her distress and symptoms could have been managed earlier, although her surgery options were unlikely to have been different. We upheld this aspect of Ms C's complaint.

In relation to the actions of the nursing staff, we found that there was a great deal of confusion about where Ms C's future treatment was to take place; an appointment had been cancelled at extremely short notice and she was incorrectly advised that treatment would be given in England. Therefore, we upheld this aspect of Ms C's complaint.

Finally, we also found that this incorrect information about Ms C's future care was included in the board's complaint response. We considered this to be unreasonable and upheld this aspect of Ms C's complaint. However, we noted that the board has already taken remedial action in relation to the issuing of the incorrect information and we made no further recommendations in light of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to consider further investigations despite the persistance of pain. 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:

• In circumstances similar to Ms C, consideration should be given to making further investigations.

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 her late son (Mr A) received from the board's mental health team. Mr A was discharged home on a community based compulsory treatment order but completed suicide around 18 weeks later. Specifically, Mrs C complained that the conditions of the compulsory treatment order were not adhered to by staff, that there was insufficient communication with Mrs C as Mr A's named person, and the board's review of Mr A's death did not include certain information which Mrs C considered relevant.

The board carried out a significant adverse event review (SAER, a structured approach to learning from an adverse event) and in their response to Mrs C, they concluded that the care Mr A received was person-centred. The board also identified some learning points in relation to managing the expectations of the named person. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse and a consultant psychiatrist (a specialist in the diagnosis and treatment of mental illness). We found that there were significant gaps and numerous retrospective entries in Mr A's medical records which were unreasonable and not in line with national guidance on record-keeping. We considered that this likely impacted on the team's ability to fully understand Mr A's health and wellbeing. There was evidence to show that Mr A did not receive the planned number of weekly visits from the team, either because he missed appointments or because the visits were not carried out. Given Mr A's complex care package, we also considered that escalation to the responsible medical officer should have taken place when there had been a nine day gap in contact or when there was a significant deviation from his care plan (only one visit a week instead of three). Therefore, we upheld this aspect of Mrs C's complaint.

In relation to communication with Mrs C, we noted that the rights of the named person are limited and there was no requirement for the team to have shared all aspects of Mr A's care with her. However, we considered it is generally good practice to communicate with the named person/family which had been part of Mr A's care plan. We found that the mental health team did not communicate reasonably with Mrs C and upheld this aspect of her complaint. However, we noted that the board had acknowledged these failings.

In relation the the SAER, we did not have significant concerns about the information Mrs C felt was missing. However, we were critical that she had not been provided with the opportunity to raise such concerns. We were also concerned that the SAER should have identified the failings in record-keeping as part of the review of Mr A's care. 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 the failings in Mr A's agreed care plan and poor record-keeping. 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:

• When significant deviation from an agreed care plans occurs, this should be escalated to the responsible medical officer for discussion and a record made of what the response to this should be.

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.