Upheld, recommendations

Summary

Ms C complained about the care and treatment provided to her son (Mr A) by the partnership after he was diagnosed with psychosis. She considered that there were issues with his treatment plan which led to him having relapses. She complained that, when Mr A was admitted to hospital, he was not able to consent for information to be shared with her. She said that this was not addressed for several weeks. Ms C also complained that, after an occasion when Mr A came close to attempting suicide, there was a delay in meeting with her to discuss this. Ms C also raised concerns about how closely Mr A was monitored in the lead up to this occasion. In particular, she had concerns that Mr A was allowed to leave the hospital unchallenged, after she had raised concerns about his mood.

We took independent advice from a consultant psychiatrist. We found that Mr A's treatment plan was reasonable, as it took into account Mr A's own wishes about his treatment. However, we found that Mr A's ability to consent to share information with Ms C was not reviewed regularly after his admission to the hospital. The partnership had acknowledged this and had apologised to Ms C. We upheld this aspect of the complaint and we made a recommendation to improve this in the future.

We noted that the partnership had acknowledged an unreasonable delay in meeting with Ms C after the occasion when Mr A came close to attempting suicide. Although we upheld that aspect of the complaint, we found that the steps they had since taken to improve communication with Ms C were reasonable, and so we did not make any further recommendations in this regard.

We found that Mr A was appropriately monitored in the days leading up to the occasion when he came close to attempting suicide. However, the day before, Ms C raised concerns about Mr A's condition with hospital staff, which we found were not recorded. We also found that Mr A had briefly gone missing from the hospital on the night before he came close to attempting suicide and that he had been noted as being agitated. Given the concerns that Ms C had raised about Mr A earlier that day, and his agitation, we considered that a suicide risk assessment should have been carried out at that time. However, we found no record that this had been done. Therefore, we upheld this aspect of the complaint and we made recommendations in light of our findings. However, we did find that it was reasonable that Mr A was allowed to leave the hospital unchallenged that day, as he was allowed unaccompanied time out of the ward as part of his rehabilitation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to record the concerns that Ms C raised about Mr A's condition. Also apologise that a suicide risk assessment was not carried out. The apology should comply with the SPSO guidelines on making an 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 been deemed incapable, the partnership should regularly review the patient's capacity to give consent about sharing information. Relatives or carers should be kept up to date on those reviews.
• All significant events should be documented in the medical records, including feedback from relatives and carers about a patient's condition.
• In circumstances similar to Mr A's in the future, staff should carry out a suicide risk assessment.

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 and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that the board did not take appropriate action in relation to an ulcer on Mrs B's daughter (Ms A)'s heel. Ms A had a number of complex health conditions, including diabetes, and Ms C complained that neither the podiatrist that saw Ms A, nor the surgeon that saw her, raised any alarm about the fact the heel wound was getting worse.

We took independent advice from a podiatrist and from a surgeon. We found that Ms A should have been seen by the lead podiatrist at an earlier point and that this may have resulted in a swifter referral to a specialist team. We also found that the podiatry team failed to appropriately use diabetic foot screening tools. We further found that the surgeon that saw Ms A recommended a treatment that would not be normal practice and did not document any reason for this. We found that whilst they reasonably arranged a scan for Ms A's foot, this should have been done at an earlier point, and a management plan should have been made. We also found that the board's own complaints investigation did not identify or address the failings in the care provided to Ms A.

We upheld this complaint. However, since the events of this complaint, the board had implemented a detailed and comprehensive action plan to improve the care pathways for diabetic feet, which we found reasonable. We, therefore, limited our recommendations to areas which we felt had not been covered by the board's action plan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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 with diabetic foot ulcers should be referred to the lead podiatrist or the vascular service as appropriate in a timely manner, and diabetic foot ulcers should be assessed in line with diabetic foot screening tools.
• In similar cases, surgeons should be aware of what action to take.

In relation to complaints handling, we recommended:

• The board's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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 and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that Mrs B's daughter (Ms A) had not been provided appropriate care and treatment for an ulcer on her heel by practice nurses. Ms A had complex health conditions, including diabetes, and over several months practice nurses were dressing and monitoring the ulcer on her heel. The wound deteriorated and Ms A had to have an above the knee amputation as a result.

We took independent advice from a practice nurse. We found that the dressings and wound cleansing products used by the practice nurses were not in line with guidance, and that the ulcer was not assessed in line with Scottish Intercollegiate Guidelines Network guidelines. We also found that, given Ms A's other health conditions, the practice nurses should have taken steps to involve other specialisms at an earlier point. We found that it was not possible to say whether an earlier referral to a specialist would have prevented the deterioration in the wound, but we found that it would have resulted in a more controlled care experience. We also found that the practice's own complaints investigation did not identify or address the failings in the care provided to Ms A. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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:

• Practice nurses and other clinical staff within the practice should be practising in accordance with the agreed wound formulary, unless there is a clear and robust clinical reason for opting for a non-formulary product, in which case, this should be clearly documented.
• Management of diabetic foot ulcers should be carried out in accordance with Scottish Intercollegiate Guidelines Network guidelines for the management of diabetic foot ulcers.
• Expert input should always be asked for if dealing with a difficult wound that is not healing.

In relation to complaints handling, we recommended:

• The practice's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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 he had been refused a patient escort to his hospital appointment. Mr C lives far away from the hospital and said that he could not travel on his own due to his health conditions. The board said that Mr C did not meet the criteria for a patient escort.

We took independent advice from a nurse. They said that there was insufficient evidence to demonstrate that the board had reasonably assessed Mr C's health conditions and their impact on his ability to travel. We considered that it was not clear why Mr C did not meet the criteria and what, potentially, would be sufficient to meet the criteria. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a full rationale for the decision not to allow him a patient escort.

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 attended the dentist to receive restoration treatment which included having a filling replaced, and previous fillings smoothed over as they still had overhangs of amalgam (mixture used to fill the teeth). The dentist who provided the treatment was undergoing vocational training, and was supervised by another dentist. Miss C complained that the treatment she received was below a reasonable standard.

We took independent advice from a dentist and found that overhangs of amalgam were still partially present, despite having been smoothed, and a significant gap was created between two teeth. Both the remnant amalgam and the gap were risks to Miss C's dental health, in particular as she had an underlying risk of tooth decay. We found that the treatment provided to Miss C was below a reasonable standard and, therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for providing treatment below a reasonable standard. 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 dentist's supervisor should ensure that the dentist has a periodontal update, concentrating on the impact of poor restoration contouring.

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 treatment a dentist provided to her over a number of years. We took independent advice from a dental adviser. We found that there was a failure by the dentist to observe decay in three teeth, and possibly other teeth. Consequently, the dentist failed to plan for the management and treatment of the affected teeth. This meant that Miss C's decay profile was wrong, and she did not receive the level of observation and intervention needed, which led to an increase in the risk of decay and a significant impact on the health of her gums. We also found that fillings placed by the dentist were of a poor standard. We concluded that the treatment provided to Miss C was below a reasonable standard and we upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to observe decay, which meant a failure to plan appropriately for the management and treatment of her teeth. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• The dentist should make a payment to Miss C, equivalent to the costs of care and treatment provided (excluding an amount already paid as a goodwill gesture) as redress for Miss C not getting the level of observation and intervention needed.

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

• The dentist should ensure that they have the professional knowledge and skills to understand and act on decay diagnosis on radiographs.
• The dentist should ensure that they have the professional knowledge and skills to achieve proper placement and finishing of fillings within teeth.

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 care and treatment his late wife (Mrs A) received during admissions to St John's Hospital, the Royal Infirmary of Edinburgh and the Western General Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing Mrs A's lymphoma (a type of cancer) during those admissions.

We took independent advice from a consultant upper-gastrointestinal surgeon and from a consultant physician. We found that appropriate investigations were carried out into Mrs A's condition. However, we found lymphoma is very difficult to diagnose and that it had presented in Mrs A in a very unusual way. We did find that Mrs A was unreasonably diagnosed with an autoimmune condition at St John's Hospital, based on blood test results that actually suggested inflammation. We found that an opinion from other relevant specialists may have avoided this misdiagnosis. We found that this error may have delayed her diagnosis of lymphoma by one month and we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for misdiagnosing Mrs A with an autoimmune condition. 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:

• Blood test results should be carefully reviewed, with the input of other medical specialists when appropriate.

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 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.