Upheld, recommendations

Summary

Mr C raised a number of concerns about the care provided to his mother (Mrs A) at Queen Elizabeth University Hospital. During Mrs A's admission, she was found to have fallen whilst in the bathroom. The nurse who found Mrs A did not identify any immediate signs of injury and noted that Mrs A had not reported loss of consciousness. Nursing staff subsequently carried out observations, and a doctor carried out an examination, noting no injuries. Following the examination, Mr C noticed that the bed sheets by Mrs A's elbow were spotted with blood and he reported this to nursing staff, who arranged for a small wound on Mrs A's arm to be dressed. The following day, Mr C noticed bruising around his mother's hairline and reported this to nursing staff, who had not previously noted this. A scan was then arranged, the results of which indicated that Mrs A had an acute subdural haematoma (bleeding in the space between the brain and the skull). Mrs A was subsequently transferred to a neurosurgical ward, and a procedure to evacuate the subdural haematoma was carried out.

A number of weeks following the fall, the board decided to undertake a significant clinical incident investigation. This took a number of months to be finalised, and it concluded that the assessment of Mrs A's risk of falling was not carried out appropriately and made a number of recommendations. To assess whether the board had taken appropriate steps in response to the failings identified, we took independent advice from a nursing adviser and a medical adviser.

Based on the nursing advice we received we could not conclude that Mrs A would not have fallen had the falls risk assessment been carried out appropriately, and had the appropriate interventions been in place. However, we considered that it was unreasonable that the board did not take the steps that they could reasonably have been expected to take to reduce the risk of Mrs A falling. We upheld this complaint, and we made a recommendation in relation to falls risk assessment.

Mr C was unhappy that nursing and medical staff failed to identify and treat his mother's injuries. In response to Mr C's complaint, the board acknowledged that nursing staff should have observed the bruising to Mrs A's head when delivering personal care and apologised that medical staff also missed this injury. The medical adviser was critical that a top-to-toe examination was not carried out by medical staff following the fall, and was also critical of how the medical examination was documented. We were satisfied that a dressing was appropriately applied to the cut to Mrs A's arm, and that a scan was arranged within a reasonable time after the bruising on her head was noticed. However, we found that the examination following the fall was not reasonable, and we upheld this aspect of the complaint. We made a number of recommendations for improvement.

We were also critical of the way the board handled Mr C's complaint. We found that staff had potentially missed an opportunity to recognise Mr C's complaint at an earlier stage, and we considered that this may have delayed the start of the complaint investigation. We noted a number of other shortcomings in the way the board handled and responded to Mr C's complaint. We upheld this aspect of the complaint and made a recommendation.

Recommendations

What we asked the organisation to do in this case:

• Send Mr C a written apology for failing to carry out a reasonable assessment of Mrs A following her fall.

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

• Junior medical staff should be trained on how to carry out appropriate assessments for patients who have fallen.
• The member of medical staff who assessed Mrs A should reflect and learn from the adviser's comments on record-keeping.

In relation to complaints handling, we recommended:

• Complaints should be handled in accordance with the proper procedure.

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

Summary

Mr C complained on behalf of his wife (Mrs A) about the care provided by mental health services at Dr Gray's Hospital. Specifically, Mr C complained about the way in which a psychiatrist and a community psychiatric nurse (CPN) handled a request for a letter for Mrs A to be excused from attending court as a witness and that they had discharged her from the service without notifying her or offering alternative support.

We took independent advice from a consultant psychiatrist and a mental health adviser. We were critical that the psychiatrist had not made a record of a phone conversation that took place with Mr C at the time to evidence the advice and support offered. This was contrary to national guidance in relation to record-keeping which we were critical of and we made recommendations in relation to this. We also found that the board had acknowledged and apologised that their psychiatrist and CPN had not properly communicated with Mrs A regarding her discharge from the service. The board said that they had taken action to remind staff to share all important communication with patients. We considered that the psychiatrist had not documented adequate reasons supporting why Mrs A was discharged, nor had they offered her the option of another consultation or seeing a different clinician. We also found that it would have been more appropriate for the CPN to have written to Mrs A and explained the options available to her in terms of continuing or not continuing the service. We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to keep appropriate records.
• Apologise to Mrs A for failing to offer her the option of a further consultation or follow-up appointment with a different clinician prior to being discharged.

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

• The findings of this report should be shown to the doctor involved to ensure that in the future timely and adequate records are maintained.

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 about the actions of their social work department. She was dissatisfied with their response and a Complaints Review Committee (CRC) was held. Ms C complained to us about the processes involved leading up to and including the CRC. In particular, she said that the terms of her complaint were not agreed with her in advance, further issues that were raised in advance of the CRC were not considered and her complaints about her dissatisfaction were not properly considered.

We made further enquiries of the council and found that contrary to their procedure, Ms C's complaints had not been agreed with her in advance. While the further information she provided was considered, it had not been acknowledged and she had not been told that it would be heard by the CRC. This led to Ms C feeling that her case had not been properly heard. We, therefore, upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should apologise to Ms C for failing to agree the terms of her complaint in advance.
• The council should apologise to Ms C for failing to acknowledge the issues she raised prior to the CRC.

In relation to complaints handling, we recommended:

• Staff who act as investigating officers should agree the terms of complaints in advance.

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 husband (Mr A) during hospital admissions to the Royal Infirmary of Edinburgh (RIE), Liberton Hospital, the Western General Hospital and Ellen's Glen House in the months prior to Mr A's death. Mrs C also complained about communication and the board's complaints handling.

The board arranged a meeting for Mrs C with staff from the hospitals involved, and provided several written responses to her complaints, including an independent clinical review of some of the complaints. The board acknowledged a number of failings, including that significant decisions to complete a 'do not attempt cardiopulmonary resuscitation' (DNACPR) form and a 'verification of expected death' form were not discussed with her or Mr A, that the nursing documentation from Ellen's Glen House was completed to a poor standard, and that all of the medical records from Mr A's admission to RIE had been lost. However, Mrs C was not satisfied with the board's response.

After taking independent medical and nursing advice, we upheld Mrs C's complaints. We found some additional failings in medical and nursing care, including that Mr A was discharged from RIE when he was not fit to be discharged, and that nursing staff did not contact the family or carry out a neurological assessment when Mr A suffered a minor head injury. In relation to Mr A's missing medical records, we were advised that the board's actions in relation to the management of files were relevant but not sufficient.

We also found failings in the board's complaints handling. On several occasions the board agreed to take action, but did not follow through on this, and the independent clinical review provided to Mrs C included inaccurate findings, which were contradicted by the board's later responses. However, in making our decision we acknowledged that the board devoted considerable time and effort to addressing the numerous points Mrs C raised, including meeting with her and writing detailed responses to her concerns.

Recommendations

We recommended that the board:

• feed back our findings to the RIE doctor who discharged Mr A, for reflection and learning;
• confirm that the consultant who put in place the DNACPR without informing Mrs C has discussed this complaint at an annual appraisal;
• demonstrate that there are robust auditing processes in place at Liberton Hospital and Ellen's Glen House, to ensure decisions about DNACPR and nurse verification of death decisions are discussed with patients and/or families;
• discuss the nursing adviser's comments in relation to the treatment of Mr A's head wound with relevant nursing staff, for reflection and learning;
• demonstrate they have taken the action identified in their improvement plan to improve record-keeping (introduction of transfer letters and discussion of the process of filing notes at a quality meeting);
• review training needs of relevant staff in relation to information governance;
• update the management of misfiled and missing records procedure to include reporting responsibilities of staff;
• apologise to Mrs C for the additional failings our investigation found;
• review their systems for tracking actions agreed with a complainant, to ensure they follow up on these; and
• confirm that the failings in the independent clinical review have been fed back to the relevant doctor for reflection and learning as part of their next annual appraisal.

Summary

Mr C complained that staff at Hairmyres Hospital failed to provide him with appropriate care and treatment.

Mr C became unwell with sepsis (an infection of the blood) following an operation to treat an abscess on his abdominal wall. He was discharged with arrangements to have his wound cared for by district nurses. Mr C was later readmitted with symptoms of pain, swelling and wound discharge and was discharged the same day. Mr C then went on to develop a hernia some months later.

Mr C raised specific concerns that the operation to treat his abscess was carried out too late in the evening. He said the surgeon did not take into account information relayed concerning a scan that he had undergone. Mr C also said a surgeon opened his wound with a scalpel to further drain it while he was on the ward. Mr C attributed his subsequent health problems to the way the board handled his condition. The board said Mr C's condition was identified accurately, and that he received appropriate surgery. They considered Mr C's subsequent problems were not due to any deficit in care.

We took independent advice from a surgeon. We found that overall, the board had provided appropriate treatment. In particular, we found that the surgeon carried out the correct operation, including taking into account Mr C's scan, and that this was not carried out at an inappropriate time. However, we did find that there was an unreasonable delay in Mr C receiving surgery, as this occurred several days into his admission. We found that the board should have made a decision and operated on Mr C at an earlier stage. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in surgery identified in this investigation; and
• consider steps they can take to reduce the impact of avoidable delays on treatment in the future.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs B about the care and treatment of her late husband (Mr A). Mr A was admitted to Queen Elizabeth University Hospital with symptoms including severe abdominal pain and weight loss. He underwent tests, including a CT scan, but nothing was found to explain his symptoms. His GP later contacted the hospital as they remained concerned about Mr A's pain, and the CT scan was reviewed. Abnormalities in Mr A's liver and abdomen were suspected, and a further CT scan and liver biopsy confirmed that he had secondary liver cancer. He was referred to oncology and died after two sessions of chemotherapy. Ms C complained that Mr A's cancer was not diagnosed earlier and that there were signs on the first CT scan that were initially overlooked.

The board accepted that there was a delay in diagnosing Mr A's cancer but said the original CT scan report was falsely reassuring. They did not consider that this delay had any bearing on Mr A's prognosis, as Mr A's cancer was advanced and would have been regarded as terminal at the time of the first scan. They noted that the missed diagnosis on the first scan had been discussed at a radiology review meeting and also fed back to the radiologist concerned.

We took independent advice from a consultant radiologist who noted that interpreting the first scan was not straightforward and that the abnormalities were subtle. Nonetheless, they confirmed that these were overlooked, leading to delay in diagnosis. We also took advice from a consultant clinical oncologist, who confirmed that the delayed diagnosis would not have altered Mr A's life expectancy but acknowledged that it would have delayed his access to palliative care services. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mrs B regarding the delay in diagnosing Mr A's cancer, and consequently the delay in him accessing palliative care services.

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 there was a failure to carry out a proper range of diagnostic tests into the possible cause of blood in his late wife (Mrs A's) urine when she was admitted to Southern General Hospital. Mrs A underwent a change of catheter and a urinary tract ultrasound. A cystoscopy (a medical procedure used to examine the inside of the bladder) was also planned, but was not carried out.

We took independent advice from a urological surgeon. We found that the treatment Mrs A received was reasonable. We also found that an ultrasound and a cystoscopy would normally be the first wave of investigations to investigate blood in urine, and in doing so investigate the possibility of cancer. While an ultrasound was carried out when Mrs A was admitted to hospital, we found that the decision not to carry out the cystoscopy at that time was reasonable. However, we found that the subsequent delay in carrying out a cystoscopy was unreasonable. While the advice we received was that an earlier cystoscopy and diagnosis of bladder cancer may not have changed Mrs A's outcome, we were concerned that the uncertainty caused Mrs A, Mr C and their family considerable distress during a very difficult time. Given the delay in carrying out the cystoscopy we upheld this aspect of the complaint.

Mr C also raised a concern that Mrs A was unreasonably discharged from the Victoria Infirmary following an emergency admission due to side effects from opiate pain relief that had been prescribed to her. Following this discharge Mrs A had to return to the hospital and was admitted a few hours later. We took independent medical advice from a consultant physician. We found that it was unreasonable that Mrs A was discharged and that, while relevant examinations were carried out, the relevant investigations were not. In particular, we found that the medical staff caring for Mrs A should have predicted the potential requirement for further naloxone (a medication used to block and reverse the effects of opiates) after the naloxone given by ambulance crew had worn off. Our adviser said that, according to the medical records, Mrs A was discharged after approximately two hours, which they considered to be too short a period in the circumstances. The adviser also considered that inadequate investigations into Mrs A's home circumstances were carried out before discharge. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mr C for the unreasonable delay in carrying out the cystoscopy.
• The board should issue a written apology to Mr C for unreasonably discharging Mrs A from the Victoria Infirmary.

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

• The board should ensure that patients with visible blood in their urine are investigated in a timely manner.
• The board should ensure that, where a patient with renal impairment or multiple medical problems has overdosed on long acting opiates, relevant investigations are carried out.
• The board should ensure that relevant guidelines are prepared on the use of naloxone in adult patients with renal impairment who have overdosed on long acting opiates.
• The board should ensure that a patient's home circumstances are adequately investigated when notification is received from a family member that they are struggling to cope at home.

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). Over the course of a number of years Mr A attended the practice with anxiety and depression. During this time, the practice treated Mr A in primary care, and did not refer him to mental health services. Subsequently, Mr A did not attend the practice with these problems for approximately 18 months. Mr A then contacted the practice and reported persistent thoughts about suicide to the GP who saw him. The GP developed a plan of management, including referring Mr A to psychiatric services. However, the referral was not processed. Mr A committed suicide approximately ten days after his attendance at the practice. Mrs C complained that the practice failed to appropriately refer Mr A to mental health services in view of his presenting symptoms.

The practice said they provided appropriate treatment based on Mr A's symptoms during his earlier attendances. They did not consider a referral was appropriate at that stage. When Mr A returned and described persistent thoughts about suicide, they said a referral was appropriate. The practice acknowledged there was an error in processing the referral, although they noted that it was unlikely Mr A would have received an appointment before his death.

After receiving independent advice from a GP, we upheld Mrs C's complaint. We found there was an administrative failing in not making the referral (as the practice acknowledged). We also found the practice should have scheduled an earlier review when Mr A re-attended the practice. However, we did not consider the practice should have made a referral at any of Mr A's earlier attendances, and we found that the care and treatment provided during this time had been reasonable.

Recommendations

We recommended that the practice:

• confirm that the GP will review the relevant National Institute for Health and Care Excellence guidance and consider identifying this as a learning need in their personal development plan;
• confirm the GP will discuss this case as part of their annual appraisal; and
• apologise for the failings identified in this investigation.

Summary

Mr C complained about the care his late wife (Mrs A) received from nursing staff during two admissions to Forth Valley Royal Hospital. On the first occasion she was admitted with sepsis (a blood infection) and on the second occasion she was admitted with a hip fracture. In particular, Mr C complained that the board failed to carry out appropriate falls risk assessments, failed to appropriately manage Mrs A's medication and delayed in obtaining a review for Mrs A following a fall. Mr C also complained that it took an unreasonable amount of time for him to be able to speak to a senior staff member about his concerns.

During our investigation we took independent advice from a nursing adviser. The adviser considered that the overall care in relation to falls assessments, monitoring, care and falls prevention was unreasonable. They also found significant failings in how Mrs A's medication was managed.

The board accepted that it took an unreasonable amount of time for Mr C to speak to a senior staff member about his concerns. They also accepted that there was a delay in having Mrs A reviewed following her fall. The board also accepted that there were significant failings in how Mrs A's medication was managed. The board identified learning as a result of the complaint.

In light of the independent medical advice we received, we upheld all of Mr C's complaints. Although the board had taken steps to address the complaint, we made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a formal apology to Mr C for the unreasonable level of care provided to Mrs A in relation to falls assessments, monitoring and care.

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

• The board should ensure that patients at very high risk of falls should be considered for referral to a falls co-ordinator or falls specialist.
• The board should ensure that in future situations similar to Mrs A's a medical review is requested sooner.

In relation to complaints handling, we recommended:

• The board should ensure that senior charge nurses, and other frontline staff, have the skills and confidence to undertake early resolution of 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 to us about the care and treatment provided to him by the board in relation to treatment for his leg problems, and their communication with him. Mr C said that after a course of foam sclerotherapy (a procedure where medicine is injected into the blood vessels, making them shrink) for varicose veins in his legs, he was in a lot of discomfort. He said that he was told at a scan a month later that he had deep vein thrombosis (a condition when a blood clot forms in a vein located deep inside the body) but that he was not given appropriate treatment for this. He also said that he had been told contradictory things regarding the clot in his leg.

During our investigation, we took independent medical advice from a consultant vascular surgeon. We found that although the treatment that was given to Mr C was reasonable, there were two occasions on which follow-up scans should have been arranged but were not. We upheld this aspect of Mr C's complaint. We also found that the board had acknowledged that communication with Mr C had been poor, and that the lack of documentation of communication evidenced this. We upheld this aspect of Mr C's complaint.

Mr C also complained to us about the board's complaints handling, specifically that it took a long time for them to issue their final response to his complaint. The board accepted that they had failed to respond to Mr C's complaint in a timely manner and we therefore upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mr C for failing to provide him with appropriate follow-up appointments after his scans.
• The board should apologise to Mr C for failing to communicate appropriately with him about the causes of his leg pain.
• The board should apologise to Mr C for failing to respond to his complaint in a timely manner.

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

• Follow-ups should be arranged for two weeks after a duplex scan shows a clot in the gastrocnemius vein.
• Details of appointments should be clearly recorded.
• Communication could be supplemented by a printed leaflet.

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.