Upheld, recommendations

Summary

Miss C had long standing problems with her ears and had a number of operations to deal with this. More recently she began to experience nocturnal seizures (seizures which occur during sleep) which she thought were related to the problems she already had. Miss C complained about the care and treatment she received and that it took too long to get a diagnosis for the seizures. She felt that she had not been listened to and had unreasonably been referred to the psychology service because of stress. The board, however, took the view that her symptoms were unrelated to her existing condition and that her care and treatment had been reasonable.

We took independent advice from consultants in neurology and ENT (ear, nose and throat). We found that the mix of the two conditions from which Miss C suffered required time and effort to investigate and to prove that they were unconnected. We found that the care she received from the ENT and neurology departments was thorough in order to exclude the possibility that Miss C's ear problems were the cause of possible brain disease. We were satisfied that she had been reasonably and appropriately treated. However, we also found that there was a delay of six months between the time her GP referred her and when she received her first out-patient appointment. Once her treatment started, we found that Miss C also had to wait too long for her scans. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in receiving an out-patient appointment and the delay in scans being carried out. 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:

• Patients should receive clinical appointments and scans/tests in a timely 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

Mrs C complained about the management of her husband's (Mr A) insulin after he was admitted to Dumfries and Galloway Royal Infirmary for treatment of a stroke. Mr A has a history of diabetes mellitus (a condition that occurs when the body cannot produce sufficient insulin to absorb blood sugar) for which he administers insulin.

In responding to the complaint, the board acknowledged and apologised for a delay in Mr A receiving insulin one evening. The board considered that, during Mr A's admission, staff had followed the correct procedures but more checks of his blood sugar and ketone levels would have allowed staff to act earlier. The board set out a number of measures that they said they had taken regarding staff training and improvements as a result of Mr A's experience.

We took independent advice from a consultant physician specialised in diabetes mellitus. We found that management of the insulin was below the expected standard, given the possibility that diabetic ketoacidosis (DKA, a serious complication of diabetes that occurs when the body produces high levels of ketones) could have been prevented by earlier recognition, more frequent monitoring and more aggressive insulin administration. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff did not specifically inform her or Mr A that he had developed DKA and urosepsis (a secondary infection that develops in the urinary tract). Mrs C said they had only been aware that Mr A had low blood sugar levels. We found that when Mr A developed DKA and urosepsis, there was no record of this having been explained to either of them at the time. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failings in communication. 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:

• Staff should be aware that early recognition of the warning signs and prompt restorative action should prevent DKA from developing.

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

Summary

Mr C complained about the follow-up care and treament he received at Dumfries and Galloway Royal Infirmary. Mr C underwent surgery for prostate cancer in another NHS board area but follow-up care was to take place within his own area. Mr C complained to the board about the way they handled his follow-up care as there were a number of delays. The board decided to undertake a Significant Adverse Event Review (SAER) as a result. Mr C was provided with a draft copy of the SAER at a meeting, however, the response to his complaint was not supplied until a number of months later with a copy of the finalised SAER report. Mr C complained to us that the board had unreasonably failed to provide him with appropriate follow-up care and treatment. He was also concered that the board had not followed their SAER policy appropriately and that there had been unreasonable failings in the way they handled his complaint.

We took independent advice from a consultant urologist. We found that there was a lack of appropriate follow-up care for Mr C and that poor communication between staff caring for him in different board areas had contributed to the issues with his follow-up. We upheld this aspect of Mr C's complaint but noted that the board had acknowledged and apologised for this failing.

In relation to the SAER, we found that it was reasonable in its findings. However, it took far longer to complete than Mr C had been advised, and we found a lack of evidence that the board had kept him updated on their progress. We upheld this aspect of Mr C's complaint.

In relation to Mr C's complaints handling concerns, we found that there had been significant delays in the investigation process and that the board had acknowledged and apologised for this. We also noted that the SAER was a separate process from the investigation of Mr C's complaints and we considered that it would have been helpful had the board's complaint response more clearly addressed the specific concerns he had raised in his original letter of complaint.

Recommendations

What we asked the organisation to do in this case:

• Review Mr C's follow-up care plan to ensure that he receives the appropriate standard going forward.

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

• There should be systems in place to facilitate communication between staff where more than one NHS board is involved in caring for a patient.

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 treatment she received from her dentist, particularly in relation to the fitting of a crown which fractured multiple times and required repairs, and areas of untreated decay.

We took independent advice from a dental adviser. We found that the treatment Ms C received from the dentist was unreasonable and we therefore upheld the complaint. The repair carried out to the crown was unreasonable, as was the failure to investigate the cause of the fracture. There were failings in the dentist's record-keeping, and we found that Ms C was incorrectly charged for the repair. There were also failings around the untreated decay, though the dentist had already acknowledged and reflected on this.

We noted that the dentist had already apologised for some failings. They had also already taken steps to improve their practice and ensure these issues did not arise again, including carrying out an audit on clinical record-keeping, and undertaking some further training. We asked for evidence of these actions and we also made some further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the shortcomings in treatment and 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.
• Refund Ms C the money charged for the crown repair.
• Consider reimbursing Ms C for the cost of the crown itself, since it broke twice soon after being fitted and had to be replaced.

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 has type 1 diabetes and needed a consultant-led maternity unit for the delivery of her baby. The board (Board 1) have a service level agreement (SLA) with another health board (Board 2) for the provision of specialist care, which meant Ms C would deliver her baby there. Ms C asked Board 1 if she could instead deliver her baby at a hospital in a different board area (Board 3), where she would have access to greater support from her family. Board 1 refused this request as they did not consider there to be any clinical need for Ms C's care to be transferred to Board 3. Ms C complained that this decision was unreasonable and was taken without consideration of her individual needs.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy, childbirth and the female reproductive system), who was critical that the initial decision was taken at senior midwife level with no apparent medical input. The board indicated that treatment outside the SLA can be approved when there are deemed to be compelling clinical grounds. We were of the view that they should, therefore, have a more robust process in place to fully assess individual medical needs. Medical input was later obtained, but only when Board 1 investigated the complaint. This showed that Ms C's consultant physician was becoming concerned that the stress from the situation was impacting on her health and diabetic control. We considered that these ongoing and developing medical reasons might reasonably have led Board 1 to reconsider their position.

We considered the reasonableness of Board 1's overall refusal, further to Ms C's complaint and their review of the position. We considered that Board 1 had not provided sufficient evidence that they took full account of all Ms C's relevant medical needs (which we noted had evolved with the passage of time). Ms C subsequently registered as a patient in Board 3 and delivered her baby there. We found that Board 1 had sent a letter to Board 3 regarding her diabetic care but her obstetric information did not appear to have been passed on despite the clearly noted requirement for a carefully planned delivery. Overall, we considered that the board unreasonably refused to request for Ms C's maternity care to be transferred to Board 3 and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to take full account of all her relevant clinical needs when refusing her request to deliver her baby in Board 3; and for failing to formally transfer all of Ms C's clinical information to the team when she decided to register as a patient there. 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 board should ensure that they have a robust process in place for considering future requests for out of area maternity referrals, ensuring that patients' clinical needs are fully considered at an appropriate level and in partnership with the patient.
• The board should ensure that all relevant clinical information is passed on to the appropriate hospital when they become aware that out of area maternity care is being delivered to one of their patients, especially where the need for a specialist care plan has been identified.

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, an MSP's caseworker, complained on behalf of a constituent (Mr A) that the council failed to appropriately investigate Mr A's reports of noise. Mr A said that renovation works being carried out by his next door neighbour were causing him severe disruption. The council had initially served an abatement notice, setting out legal time restrictions for the hours the works could be carried out. However, Mr A said that he had repeatedly reported that works were ongoing outwith the specified hours and that the council had been unable to attend to witness the noise and enforce the notice. By the time that the council were able to attend out-of-hours, the works were mostly complete, with remaining works taking place during the specified hours.

We took independent advice from an environmental health adviser. We found that the council had no formal policy or procedure relating to the investigation of noise and enforcement of abatement notices. The council said that a policy would not cover the complexity of noise complaints and would restrict their staff from using their professional judgement. The adviser noted that Scottish Government guidance suggests that local authorities should have clear policies and procedures in place to govern the investigation of noise nuisance. The guidance also suggested that those policies and procedures should set out clear timescales for response, along with details for out-of-hours provision. We considered that the council's reason for not having these policies and procedures was unreasonable. We also found that the council had taken too long to attend and investigate Mr A's ongoing reports of noise, both during and outwith normal working hours. Finally, we noted that the were a number of documents missing including records of phone calls made by Mr A and details of the site visits the council did carry out. For these reasons, we considered that the council failed to appropriately investigate Mr A's reports of noise and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to appropriately investigate his reports of noise. 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 council should have a clear procedure for noise management and investigation, in line with the Scottish Government guidance. This will include full details of out-of-hours arrangements and timescales for attendance following noise reports.
• Full records should be made of investigations, which should be made readily available for any complaint investigation.

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

Summary

Mrs C complained on behalf of her late husband (Mr A) who had been a patient at a clinic within the partnership. Mr A was admitted to the clinic as a voluntary patient after he attempted to take his own life. A number of days later, Mr A was allowed to leave the clinic on pass and return home. Within a day of returning home, Mr A completed suicide. Mrs C complained that the partnership failed to provide Mr A with reasonable care and treatment both when and after he was admitted to the clinic. Mrs C also complained that the partnership failed to follow their complaints procedure.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that as Mr A was admitted as a voluntary patient with capacity, he was able to leave the clinic any time he wished. However, it was noted that there was no record of Mr A undergoing a full assessment. A comprehensive mental state assessment should have been completed both on admission and before Mr A left the clinic on pass. We also found that there was no evidence of planned, structured nursing engagement in Mr A's care. Therefore, we upheld this complaint. However, we were also clear that even had these shortcomings not occurred, the outcome for Mr A would have been unlikely to have been different.

In regards to complaints handling, we found that the partnership failed to respond correctly to Mrs C in line with their complaints procedure. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to deal with her complaint in a timely manner in accordance with stated procedures. 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 quality of medical note-taking should be improved.
• Nursing staff must ensure that there is a daily, structured engagement with patients, and that there is a record made of this engagement.

In relation to complaints handling, we recommended:

• Complaints should be responded to in accordance with stated procedures.

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

Summary

Miss C complained about the level of communication provided by the partnership regarding the care of her father (Mr A). Mr A was moved from a rehabilitation centre to another tenancy, however, this property did not suit his needs and Mr A returned to the centre. Miss C, who has financial power of attorney, complained that the partnership failed to reasonably involve Mr A's family members in decisions about his care. Miss C also complained that Mr A's care plan was not shared with his family, or made available to the rehabilitation centre, with no provisions implemented to ensure a smooth transition to his new tenancy.

Miss C complained to the partnership who advised that they were attempting to balance promoting independence for Mr A, who did have capacity, against involving his family. They acknowledged that communication had been poor but were vague about what steps would be taken to avoid similar problems occurring in the future. Miss C was unhappy with this response and brought her complaint to us.

The partnership responded to us and explained that on further review, they accepted many of the failings that Miss C identified in her complaint. We noted that communication had been poor between the partnership and Miss C and that relevant parties had not seen the content of the care plan. We upheld Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and his family for the distress and inconvenience caused by these issues. 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:

• Staff should ensure adequate communication with a service user's family and should make sure that communication with the family is appropriately documented.
• The partnership should ensure that staff reflect on and learn from the findings of this investigation. In particular, there should be reflection on ensuring family members have sight of the up-to-date care plan and that existing care providers are appropriately informed of plans (and transition provisions) prior to a service user moving out of the care setting.

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 to us about the care and treatment her mother (Mrs A) had received after she was admitted to St John's Hospital with bipolar disorder (a mental health condition marked by alternating periods of elation and depression).

Ms C complained about a number of issues in relation to the nursing care provided to Mrs A. We took independent advice from a mental health nurse. We found that it had been unreasonable for nursing staff to allow Mrs A off the ward without an escort. Although Mrs A came to no harm, her safety and wellbeing were placed at undue risk as a result of this. We also found that, despite it being known that Mrs A had medication compliance issues, there was no evidence in the records of a coherent care plan designed to promote her compliance with oral medication. Neither her care needs nor her nursing care had been effectively planned or kept under review. Care plans in the records were dated four weeks after Mrs A had been admitted to hospital and we found that the manner in which the documentation had been used and completed was ineffective and unreasonable. In view of these failings, we upheld Ms C's complaint about the nursing care provided to Mrs A.

Ms C also complained about a number of aspects of the psychiatric and medical treatment Mrs A received in the hospital. We took independent advice on these issues from a psychiatric consultant. We found that there had been a delay in actioning Mrs A's electrocardiograph (ECG - a test that records the electrical activity of the heart) results and that the consultant psychiatrist had failed to make themselves aware of these results. We also found that it was unreasonable that specialist cardiology advice was not sought and that anti-psychotic drugs were prescribed to Mrs A without attention being paid to the cardiac risks or guidance being given to staff that she should be closely monitored after taking these. In addition, Mrs A received two anti-psychotic drugs at the same time, when the intention had been for staff to give Mrs A either one or the other. We also received advice that an alert should be put on Mrs A's records regarding one of the anti-psychotic drugs. We further found that the frequency of consultant review over a period of ten days had been unreasonable as adequate staff cover was not in place. Whilst it had not been unreasonable to start the application process for a compulsory treatment order for Mrs A, it was unreasonable that this had been done without a medical examination being carried out. We also found that staff failed to give Mrs A vitamin replacements that had been agreed. In view of these failings, we upheld Ms C's complaint about the psychiatric and medical treatment provided to Mrs A.

Finally, Ms C complained that the board had failed to provide a reasonable response to her complaint. We found that the board's response to her had not been reasonable, particularly that they had not informed Ms C of the outcome of their investigation into her complaints about staff behaviour. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide nursing care and psychiatric and medical treatment to Mrs A, and for failing to provide a reasonable response to Ms C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Consider putting an alert on Mrs A's records that she should not be prescribed one of the anti-psychotic medications in future.
• Inform both Ms C and us of the outcome of their investigation into Ms C's complaints about staff behaviour in relation to Mrs A's case.

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

• Relevant staff should be fully aware of their responsibilities in relation to the application of Nurses Holding Power under the Mental Health Act.
• Template documentation introduced to ensure the quality of record-keeping should be completed in full and as intended in order that nursing care, including medication compliance, is effectively planned, documented and kept under systematic review.
• Robust systems should be in place to ensure the results of medical investigations are accessed, recorded, considered and actioned in good time.
• Prescribing clinicians should be aware of the accepted prescribing guidance, especially with regard to the use of higher risk medications (such as some anti-psychotics) in vulnerable patient groups (such as the elderly) and there should be adequate processes in place for the physical monitoring of patients when such medications are administered.
• There should be adeqaute arrangements in place to cover medical staff's leave to ensure that all reasonable requests by patients and carers for consultant review are met.
• Staff prescribing medication should ensure that they provide appropriate guidance on when and how the medication is to be given.
• All staff taking decisions under the Mental Health Act should have due regard to the principles of the Act, as they are required to do, and adequate records should be made of these decisions and the rationale for reaching them.
• Patients should be given vitamin replacements where this has been previously agreed and there is no clinical reason not to give it.

In relation to complaints handling, we recommended:

• Complaints should be investigated appropriately.

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

Summary

Mr C complained about treatment that he received at Raigmore Hospital when he was admitted via the emergency department. Mr C had undergone a vasectomy procedure (a procedure where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) over two weeks earlier and had developed painful swelling. Mr C complained that, after admission for assessment/investigation in the urology department, he was examined and then discharged with advice to manage his symptoms conservatively. Mr C later had to be admitted for a number of days for treatment of an abscess.

We took independent advice from a consultant urologist. We found that there were several factors in Mr C's presentation that meant that, on balance, a more proactive approach to his symptoms would have been appropriate. We upheld this aspect of his complaint.

Mr C also complained that the board's response to his complaint was inaccurate. We found that key dates in the response were incorrect. We noted that the board acknowledged this failing and advised that they had taken steps to address it going forwards. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to consider and/or document consideration of, a more proactive approach to Mr C's care and for the inaccuracies in the final response to Mr C's complaint. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org/leaflets-and-guidance.

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

• All relevant clinical factors should be taken into account and this should be apparent from the notes made in the contemporary clinical 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.