Mid Scotland and Fife

Overview

The complainant (Ms C) raised a number of concerns that her spinal injury was not properly assessed by staff at the emergency department and that a log roll was performed improperly leading to further injuries, and that there were further unreasonable delays by staff at the orthopaedic ward she was admitted to in fully investigating and identifying her spinal injury.

Specific complaint and conclusion

The complaint which has been investigated is that Stirling Royal Infirmary's identification and treatment in mid-June 2011 of Ms C’s spinal injuries were below a reasonable standard (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  carry out an audit of the standard of their trauma management;

(ii)  ensure that the findings of National confidential enquiry into patient outcome and health report Trauma who cares? are implemented and amend their protocol accordingly, in particular to ensure that senior emergency department doctors will be available to initially assess and provide on-going advice for all victims of trauma;

(iii)  review the actions of Consultant 1 in light of this report and take appropriate action; and

(iv)  make a further formal apology to Ms C for the failures identified.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) raised a number of concerns with Lanarkshire NHS Board (the Board) concerning the care and treatment her father (Mr A) received for a gangrenous toe between 4 January and 12 March 2011 while a patient in three different hospitals, including Monklands General Hospital (Hospital 1), Hairmyres Hospital (Hospital 2) and Wester Moffat Hospital (Hospital 3). Mr A died from sepsis (a bacterial infection in the bloodstream) on 12 March 2011.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the treatment provided to Mr A for his gangrenous toe was inadequate and failed to address the infection and prevent him contracting sepsis (upheld);
• (b) during Mr A's admissions to the three hospitals, staff unreasonably failed to recognise, monitor and address his pain, agitation and confusion (upheld);
• (c) between 9 and 10 March 2011 Mr A's medication was inappropriately changed causing him to become very distressed and unresponsive (upheld);
• (d) there was an unreasonable delay in transferring Mr A to Hospital 1 on 12 March 2011 when his condition had deteriorated (upheld); and
• (e) during Mr A's hospital admissions from 4 January to 12 March 2011, the family constantly raised their concerns about Mr A's deteriorating condition but these were unreasonably ignored (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensures that Doctor 1 reflects in his annual appraisal on Adviser 1's comments in terms of the lack of evidence in the medical records to show that all surgical options were considered and discussed with Mr A and the family where relevant;
• (ii) review the application of the MEWS chart in Hospital 3 to ensure that staff can readily identify patients who have deteriorated and require urgent attention;
• (iii) conduct a significant event analysis with regards to Mr A's transfer from Hospital 3 to Hospital 1, to ensure that in future patients who are significantly unwell and deteriorating are transferred in a timely manner. This should also take into account Mr A's pain management at Hospital 3; and
• (iv) apologise to Mrs C and the family for the failings identified in this report.

Overview
The complainant (Mr C) complained about the handling by the Public Standards Commissioner (the PSC) of a complaint Mr C had raised concerning the actions of a councillor (the Councillor). Specifically, he complained that the PSC had failed to investigate his complaint adequately and that there were errors in the PSC's Note of Decision which remained uncorrected.

The Scottish Public Services Ombudsman Act 2002 invests in the SPSO powers to investigate the administrative and procedural actions of public bodies in Scotland, including whether there is evidence of service failure. The PSC is a public body which is named within the Act and, therefore, comes within my remit. Given this, I consider the PSC should be open to scrutiny of his administrative and procedural actions by my office in the same way as any other organisation under my jurisdiction. Unfortunately, in practice this has not been the case. I have found the actions of the PSC in response to my enquiries on this complaint and others to be at times obstructive and unhelpful and not what I would expect from a public body. I consider it necessary to take the unusual step of placing on public record the PSC's refusal to cooperate fully with my investigation of this complaint and, in particular, his refusal to release all the information I requested during the course of my enquiries. I do so in this public report.

From the outset and during the course of my investigation the PSC repeatedly questioned my jurisdiction to investigate Mr C's complaint and refused to provide me with all the information I requested, in particular copies of interview notes and a full, unredacted, schedule of those interviewed by his Investigating Officer. Correspondence with the PSC was protracted which severely hampered my investigation and, in addition, caused undue delay in my consideration of Mr C's complaint.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) an Investigating Officer (the Investigating Officer) acted unreasonably in accepting the Councillor's testimony without scrutiny (not upheld);
• (b) the Investigating Officer acted unreasonably by failing to conduct interviews with all relevant witnesses (not upheld);
• (c) the Investigating Officer failed to prepare adequately for the interview with Mr C because he was not aware of contemporaneous notes which had been previously provided by Mr C (not upheld);
• (d) the Note of Decision failed to adequately make clear that Councillor X's statement about the Councillor's conduct (at paragraph 4.14) was a statement of opinion, rather than a statement of fact (not upheld);
• (e) the Note of Decision was not objective and made subjective comments, specifically at paragraphs 5.3, 5.4, 5.6 and 5.8 (not upheld);
• and
• (f) the Note of Decision was factually inaccurate at paragraph 5.9 in relation to the date of the meeting and remains uncorrected (upheld).

Redress and recommendations
The Ombudsman recommends that the PSC:

• (i) takes steps to correct the Note of Decision and web summary to record the date of 26 September 2011.

The PSC has accepted this recommendation and has already acted upon it accordingly.

Note:  From 1 July 2013 the Commission for Ethical Standards in Public Life in Scotland and its two existing members - the Commissioner for Public Appointments and the Public Standards Commissioner - were restructured to establish one new office of the Commissioner for Ethical Standards in Public Life in Scotland.