Upheld, recommendations

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Ms C complained that Mr A did not receive a reasonable standard of surgical care and treatment when he was admitted to Raigmore Hospital for an operation. During the operation, Mr A suffered an ureteric injury (an injury or cut to the ureter - a tube that carries urine from the kidneys to the urinary bladder). Ms C said that Mr A was not warned of the risk of ureteric injury when he consented to the procedure and that the injury itself was an unreasonable surgical error. Ms C also said that the injury was not identified and treated within a reasonable time. As a result of the failings, Mr A has endured poor health and the quality of his life has significantly deteriorated. It was also likely that Mr A would require further surgical procedures.

We took independent advice from a colorectal surgeon. We found no evidence that the specific risk of ureteric injury was discussed with Mr A during the consent process, which was unreasonable and contrary to the relevant guidance. We also found that the ureteric injury was a surgical error which had an adverse outcome and that it was, to an extent, avoidable. We also found that there was an unreasonable lack of detail in the operation note which may have helped clinicians to be more alert to post-operative complications, although we found that the standard of post-operative care and treatment provided was reasonable. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to follow the relevant guidance on consent and ensure sufficient care was taken during the procedure and in completing the operation note. 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 consent process and related documentation should be reviewed so that clinicians properly obtain and document consent for procedures. The surgeon involved should reflect on this case in their annual appraisal.

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, who works for an advice and support agency, complained on behalf of his client (Mrs A) about aspects of her admission at Royal Alexandra Hospital. Mrs A was admitted to the hospital after she experienced flu-like symptoms. She was initially treated in the acute medical unit before being transferred to the acute stroke unit. Following a CT scan, a diagnosis of dural venous sinus thrombosis (a type of blood clot that affects part of the brain) was confirmed. Mrs A continued to receive care on the ward, and after she was able to move independently, she was discharged home with a follow-up consultation arranged in the neurology department.

Mrs A was unhappy about the lack of information provided to her about her condition, during her admission. She said that she was not informed that she had two clots in her brain until she attended a consultation with the neurologist three months after discharge. In response to the complaint, the board said that the stroke physician recalled discussing the diagnosis and the need for anticoagulation treatment (treatment with drugs that reduce the body's ability to form clots in the blood) with Mrs A, and also recalled Mrs A's agreement to this treatment. Mrs A was unhappy with this response and brought her complaint to us.

We took independent advice from a medical adviser with experience in stroke care. We found that the care and treatment provided to Mrs A was of a good standard. However, there was no documentation indicating that Mrs A was given an explanation of what was being done, and why, at the time of her treatment. The adviser said that it would have been good practice to record the important parts of the communication with the patient. We could not find evidence of this in the board’s record-keeping and we, therefore, were not satisfied that Mrs A was provided with appropriate information about her condition during her admission. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to provide her with appropriate information about her condition and any anxiety this might have caused her. 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:

• Medical staff should provide patients with the information they want or need to know in a way they can understand, and ensure this is documented.

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 care and treatment provided to her late mother (Mrs A) at Queen Elizabeth University Hospital. Miss C complained that both the nursing and medical care and treatment provided to Mrs A were unreasonable.

We took independent nursing advice. We found that, whilst a number of aspects of nursing care and treatment were reasonable, there was a failure by staff to discuss continence issues with Mrs A. We also found that nursing staff failed to complete fluid balance documentation fully and accurately, and failed to appropriately complete pressure ulcer risk assessments. We also found that there were issues with infection prevention and control. We upheld Miss C's complaint about the nursing care and treatment provided to Mrs A.

We also took independent advice from a consultant physician. We found that some aspects of medical care and treatment provided to Mrs A had been reasonable, however we determined that the frequency of dosing of morphine (a pain relief medication) was unreasonable and failed to take into account Mrs A's kidney function. We also found that there was a failure to document Mrs A's adverse reaction to tramadol (a pain relief medication) appropriately. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide a reasonable standard of nursing and medical care and treatment to Mrs A. The apology should meet the standards set out in the SPSO guidance on apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• When a patient has continence issues, these should be discussed with them and their continence should be assessed. They should be assisted to manage any issues in a way that protects and promotes dignity, in line with the Nursing and Midwifery Code.
• Fluid balance charts should be fully completed when required.
• Pressure ulcer risk assessments should be completed when required.
• Infection prevention and control guidance, such as the Healthcare Improvement Scotland standards for Healthcare Associated Infections, and the National Institute for Health and Care Excellence quality statement on Vascular Access Devices, should be followed.
• Kidney function should be considered when prescribing morphine.
• If a patient suffers a reaction to medication, this should be documented.

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

Summary

Ms C, who works for an advocacy agency, complained on behalf of her client (Ms A). Ms C complained that Ms A did not receive a reasonable standard of psychiatric care and treatment when she was admitted to the Royal Alexandra Hospital. Ms A had been unwell and when she was admitted to hospital a psychiatrist diagnosed her as suffering from anorexia nervosa (an eating disorder) and implemented a care plan. Ms C said that Ms A did not agree to all aspects of the care plan, which she felt was very restrictive and intrusive, and that the communication with her and her family about the severity of her condition and treatment decisions was unreasonable.

We took independent advice from a psychiatry adviser. We found that, while there were no failings in relation to the psychiatric assessment and treatment provided to Ms A, the board had failed to evidence that Ms A had fully consented to her treatment, and that there were failings surrounding the extent to which she was informed of the details of her proposed care plan. We were also concerned that such a restrictive and intrusive care plan was implemented when Ms A disagreed with it, and that it was not subject to mental health legislation which would have afforded protection to Ms A. As a result, we found that Ms A was likely to have experienced distress which may have a long-term impact on her future relationships with mental health professionals. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to evidence consent to treatment. 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:

• Care plans (in particular intrusive or restrictive care plans) should be fully explained to patients and relevant consent procedures should be followed and clearly documented.
• Professionals taking decisions about detention under the Mental Health Act should be mindful of de facto detention (where a patient feels under pressure to agree to admission to hospital or to remain in hospital, often because they feel threatened by the possibility of detention, and are, therefore, not giving valid consent to their stay in hospital) and should document their reasoning for their decisions (including consideration of the mental health legislation) clearly.

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 had been on a waiting list for a knee operation for a number of months and, despite the board telling him that he would undergo the operation within 12 weeks, it took approximately five months after Mr C was first put on the waiting list for him to have the operation. Mr C said this was contrary to the treatment time guarantee (12 weeks) and did not take into account his clinical need. Mr C had told the board he was willing to travel to any hospital in the UK to undergo the operation. Mr C said that, as a result of the board's failings, his physical and mental health had deteriorated. Mr C complained to us that the board failed to provide him with a knee operation within a reasonable time and that they failed to respond to his complaint in a reasonable way.

We took independent advice from an orthopaedic adviser. We found that the board's failure to meet the treatment time guarantee or consider other healthcare providers meant that Mr C suffered pain and discomfort for number of months, with implications for his emotional health as a result. We also found it unreasonable that, at times, Mr C had to take the initiative to find out what was happening once the 12 weeks treatment time guarantee period had passed. We were not satisfied from the evidence available that the board had reasonably had regard to the legislation concerning the treatment time guarantee, and we upheld the complaint.

In relation to complaints handling, we found that the board had wrongly told Mr C that it was not NHS policy to offer surgery outwith the health board area when the guidance around the treatment time guarantee is clear that one of the things health boards must do when the guarantee is breached is consider alternative providers within and outwith Scotland and the NHS. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide treatment within a reasonable time. 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:

• Identify any training needs to ensure staff fully understand the legislation and guidance around the treatment time guarantee, and its application.

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

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) during her admission to the Royal Alexandra Hospital. Mrs A suffered two falls while in the hospital. Ms C complained that the standard of nursing care and treatment provided to Mrs A was unreasonable. We took independent advice from a nursing adviser. We found that, in general, the nursing care was reasonable and the action taken by nursing staff to assess and protect Mrs A against the risk of falls was reasonable. However, the advice we also received was that Mrs A should have been referred to the falls team earlier than she was and that one of the two falls had not been recorded on the computer system which is used to record clinical incidents, such as falls. This computer system is an important mechanism to record incidents so that learning and improvement can take place. On balance, we upheld Ms C's complaint about the nursing care and treatment provided to Mrs A.

Ms C also complained that the medical care and treatment provided to Mrs A was unreasonable. We took independent advice from a consultant in general medicine. We found that, in general, the medical care and treatment was reasonable. However, we also found that the assessment carried out after the first fall was inadequate and that there was no evidence in the medical records that a medical review had taken place after the second fall. In addition, we found that the communication by medical staff was poor and that they had not fully explained the prognosis for Mrs A and their concerns about her recovery. Given the failings identified we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to adequately review Mrs A after her falls, and for failing to adequately explain her prognosis to her family. 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 a full medical assessment following a fall.

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 that the practice delayed in referring his late father (Mr A) for appropriate specialist investigation of his iron deficient anaemia (a condition where the blood lacks an adequate amount of healthy red blood cells). Mr C considered that an urgent colonoscopy should have been arranged, in line with cancer referral guidelines. He also raised concerns about the chosen referral pathway once a referral was eventually made, as the referral was to a vascular surgeon rather than directly for colonoscopy. Mr A was subsequently diagnosed with colorectal cancer which was not amenable to treatment and he later died. In responding to Mr C's concerns, the practice said they did not deem an earlier referral appropriate at the time in light of Mr A's other complex medical conditions.

We took independent medical advice from a GP, who advised that there were no current complex medical conditions which could have explained the significant deterioration in Mr A's red blood count. As such, they advised that cancer referral guidelines should have been followed and Mr A should have been appropriately assessed and referred for urgent investigation. We found no evidence of an appropriate examination having occurred and a referral was not made until almost nine months after iron deficient anaemia was diagnosed. We found that the referral should have been sent to a gastroenterologist or surgical doctor, rather than a vascular surgeon. In addition, the adviser highlighted that Mr A was prescribed an inappropriate dosage of iron supplements and he was not adequately monitored to assess his response to these. We concluded that there was an unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficient anaemia, and an unreasonable delay in arranging appropriate specialist investigation. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficiency anaemia; and the unreasonable delay in arranging appropriate specialist investigation. 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 GP involved in Mr A's care should refer themself to NHS Grampian's clinical support group for review of their knowledge and practice in relation to clinical assessment, prescribing and referral guidelines.

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 husband (Mr A) about the care and treatment he received from the board at Dumfries and Galloway Royal Infirmary. Mrs C complained that there was an unreasonable delay in diagnosing that Mr A was suffering from renal cancer, that there was an unreasonable delay in providing him with treatment and that staff had failed to communicate appropriately with Mr A and his family about his diagnosis and treatment.

We took independent advice from a consultant urologist who said that there was a severe failure to follow-up on a radiologist's report of a scan. The radiologist had suspected that an area of abnormality which showed in Mr A's kidney was renal cancer and had made a recommendation that the scan should be discussed at a urology multi-disciplinary team meeting (MDT). The radiologist's recommendation to discuss this at MDT was not actioned. There was also a failure to mention the scan finding in any of the correspondence on Mr A's discharge from the hospital. As a result, the suspected renal cancer was neglected until the same renal mass was found, by chance, a number of months later when Mr A had a scan to investigate a problem that was unrelated to his renal cancer. While it appeared that Mr A's tumour had not progressed when found, we found that the delay was unacceptable and that the diagnosis, management and treatment of his renal cancer was well below an expected standard. We upheld Mrs C's complaints about delays in diagnosis and treatment.

We also took independent advice from the consultant urologist, as well as a nursing adviser, about how staff communicated with Mr A and his family about his diagnosis and treatment. We did not find any reference in Mr A's medical records of medical staff having a discussion with him about his cancer diagnosis and treatment. We found that the actions taken by nursing staff had fallen short of the standard expected and needed for Mr A and his family 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 Mrs C and Mr A for:
• an unreasonable delay in diagnosing that Mr A was suffering from renal cancer;
• an unreasonable delay in providing treatment to Mr A; and
• a failure in communication.
• 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:

• A system should be in place to ensure that unexpected findings of scans are appropriately reported and acted upon in a timely manner.
• It should be ensured that radiology are summarising any significant incidental findings at the end of a scan report, as per the requirements of a previous audit, and that these findings are brought to the attention of relevant staff in a timely manner.
• Staff should be aware of the importance of communication with patients and their families. Newly appointed staff should be supported and mentored in this regard and provided with appropriate training.

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 the council as her bins were not being collected as required. Ms C was part of an assisted take out service due to her ill health but her bins were not always being lifted or, when they were, they were not returned to the correct place. Ms C made numerous complaints about this but believed that the situation noticeably worsened when she witnessed her neighbour speaking with a member of staff who, following the conversation, did not empty Ms C's bin. She was of the view that her neighbour was influencing staff not to empty her bins as part of a long running dispute. The council's response was to advise Ms C that she needed to leave her bins within the boundary of her property, and not place them on the shared driveway, as this was confusing for staff. Ms C remained unhappy with the council's position and brought her complaint to us.

Ms C complained that the council failed to provide a reasonable bin collection service and that their response to her complaint was unreasonable. We investigated information provided by both parties and advised Ms C we would not be investigating her neighbour's involvement as records from the council showed that Ms C had been experiencing this problem long before the incident with her neighbour. The records from the council showed a clear pattern of repeated failings. We upheld Ms C's complaint and asked the council to apologise to her for continually failing to empty her bins. We also noted the council had introduced a number of new processes to increase accountability for staff and they hoped this would see an improvement in service provision. We asked the council to evidence the impact of the changes they had made.

Regarding the council's response to Ms C's complaint, we found that the response was inadequate as it appeared to suggest Ms C was to blame for her bins not being emptied. We also found that the changes that the council told us they had implemented to improve the service were not referred to in their complaints response. 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 repeated failings when collecting her bins and for the poor content of the response to her 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

Mr and Mrs C complained about the council as they were unhappy with the way their child (child A) was dealt with when they suffered a head injury at their primary school. The head injury occurred when child A fell during playtime. Following the injury they were confused, distressed, and were suffering from loss of memory. Mr and Mrs C felt that an ambulance should have been called immediately. Instead, the school observed child A for a short time, before calling Mr and Mrs C and asking them to pick child A up and take them to the GP. This meant that there was a period of around 45 minutes from the injury occurring to them attending to pick up their child. Mr and Mrs C complained that the relevant council procedure was not appropriately followed when the school were dealing with child A's head injury. Mr and Mrs C were also dissatisfied with the standard of the council's complaints handling.

The council provided us with a copy of their Accidents to Pupils procedure, which instructed staff on when emergency medical assistance should be sought for head injuries, as well as providing more general guidance about how injured children should be transported to hospital if medical treatment not needing an ambulance was required. The procedure said that an ambulance should be called immediately where: the child was unconscious for any length of time; the child was vomiting frequently; neck pain was associated with the injury; or where the child's condition was 'giving cause for concern'. It appeared clear from the council's records that staff were concerned by child A's condition. This is why staff requested the child was collected and taken to their GP. However, the procedure required that they should have called an ambulance or, if they did not consider their condition serious enough to warrant emergency transport, they should have arranged for them to be transported directly to hospital by taxi or a member of staff's personal vehicle. Instead, they attempted to call Mr and Mrs C, resulting in the delay of around 45 minutes before they could collect their child and seek medical attention for them. We upheld the first complaint.

Further to this, we did not consider that the council's Accidents to Pupils procedure was sufficiently detailed for use by non-medical staff. We took independent advice from a GP adviser and we were advised that child A's condition should have been a cause for concern. The adviser's recommendation would have been that an ambulance was called. However, it is not reasonable to expect school staff to have detailed knowledge of complex medical issues, which is why it is important that the council's procedures are robust and give clear guidance that is easily understood. The adviser suggested that the school should liaise with NHS 24 to review the Accidents to Pupils procedure to ensure that it is both manageable for their staff and clinically sound.

We considered that the council's complaints handling had been unreasonable. In particular, we felt that a reasonable investigation should have highlighted that the school's failure to arrange direct transport to hospital was in clear contravention of the Accidents to Pupils procedure. As such, we also upheld the second complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to follow the Accidents to Pupils procedure, for the delay this caused in child A receiving medical attention and for failing to identify this as part of their complaints investigation. 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 liaise with NHS 24 to review the Accidents to Pupils procedure.
• All relevant staff should be aware of the Accidents to Pupils procedure and ensure it is followed when a pupil is injured.

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.