South of Scotland

Summary
Mrs C complained about how a health board responded to concerns raised by the family of her infant granddaughter (Miss A).  The family were concerned about a change in Miss A's behaviour when she was around 17 months old, which they believed were due to possible abuse or maltreatment whilst Miss A was in the care of her father.  The family had approached their GP, who referred them to a consultant paediatrician.  The paediatrician had examined Miss A, but reported no concerns.  Mrs C and Miss A's mother felt that the child had not been properly assessed and that the report produced did not provide an accurate account of the examination.

Miss A was referred to Child and Adolescent Mental Health Service (CAMHS), but the family felt that again Miss A was not appropriately assessed.  The family requested a second opinion, but did not receive one.  We investigated, and upheld, Mrs C’s complaints that the board failed to respond appropriately to serious concerns raised about a child, and that they unreasonably failed to explain to Mrs C their role and remit in this matter.

This report concerns issues around child protection.  I am conscious this is a highly complex and emotive area both for families and the professionals involved.  It is important, therefore, to be clear about the remit and scope of the investigation and subsequent report. In this investigation, I have only considered the information provided by the board, in the form of Miss A's medical records.  Child protection is a multi-agency responsibility and it should not be inferred from this report that the board was the lead agency with responsibility for child protection.  It also should not be inferred that this report proves that abuse was perpetrated on a child.  Although I accept the board did not have the lead role in child protection, however, it became clear from the advice provided that there were failings in its involvement for which it should take responsibility.

The failings identified relate primarily to the failure to record and document examination of a child to the requisite standard.  Although my office can and does consider clinical judgement, that is not the area that is criticised in this report.  I have taken the decision to stress this, in view of the subject matter and to forestall any misinterpretation or extrapolation from the report itself.

In order to investigate these complaints, I took independent advice from a consultant paediatrician and a consultant psychologist.  I decided to issue a public report on this complaint due to the evidence that the family have suffered a significant personal injustice as a result of the board's failings.  Given the sensitivity of the matters raised in the report, I also decided to anonymise the board in order to protect the identity of the family.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  carry out a review of Miss A's assessments by both the paediatric and psychology services; 8 December 2015
• (ii)  include the findings of these reviews in the subsequent appraisals of the doctors who carried out Miss A's appraisals; 29 February 2016
• (iii)  remind all staff involved in child protection work of the importance of following current guidance on examining and recording findings when assessing children; 3 November 2015
• (iv)  review the investigation of Mrs C's complaint in light of the failure to respond to it fully; 17 November 2015
• (v)  review what information is provided to families about the CAMHS service prior to referral, to ensure the reasons for referral are clear; and 17 November 2015
• (vi)  apologise unreservedly to the family for the failings identified in this report. 3 November 2015

Summary
Mr C was an older man with multiple health problems; in July 2013 he suffered a fall at home and fractured his hip.  He was taken to his local hospital, with the intention being he should be transferred to Raigmore Hospital for surgery.  Mr C was not transferred until two days after the fall, and surgery was performed three days after the fall.  He spent time recovering in another hospital after the surgery, and was discharged in August 2013. Mr C died in May 2014.

Mr C's wife (Mrs C) complained to Highland NHS Board (the Board) about the length of time taken to transfer Mr C to Raigmore Hospital, particularly taking into account the amount of pain relief that he was being given at the local hospital.  She felt he should have had surgery within one day, given his multiple health problems, and that the delay and use of pain relief had contributed to his poor recovery and subsequent decline in health.  The Board apologised for the distress caused and said that due to bed pressures it had not been possible to transfer Mr C earlier, but that appropriate care was being given by the local hospital and that there had been no detrimental effect on Mr C. I obtained further information about the other hip operations being performed over the relevant period.  The Board said those operated on earlier had been admitted to Raigmore Hospital directly, and that Mr C's transfer had been delayed further by a lack of available orthopaedic receiving beds.

My investigation found that whilst the standard of care provided at the local hospital was reasonable, the delayed transfer meant Mr C received a large quantity of morphine, which has potential side effects which Mr C went on to suffer.  In addition, the local hospital did not have the facilities required to provide the type of care outlined within the relevant national guidelines for patients with hip fractures.  I found that Mr C was an emergency trauma patient and that, despite the Board's position that such patients would be prioritised over routine and elective patients, he was not prioritised appropriately.  The information provided about the other procedures performed over the relevant period indicated there were no issues with theatre or surgical team availability.  Mr C had to wait on the basis that he was admitted to a local hospital rather than Raigmore Hospital directly.  The importance of the timing of such surgery, in terms of the outcome, is also highlighted in the relevant national guidelines.  I was critical of the Board's actions, particularly given the adverse outcome for Mr C.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  provide evidence that they have procedures in place to ensure that when emergency trauma patients require transfer to an orthopaedic unit for treatment, they appropriately prioritise in accordance with their clinical need;
• (ii)  carry out an audit of the last 50 patients admitted to Raigmore Hospital for hip fracture surgery and detailing those who presented at the emergency department (at Raigmore Hospital) and those who presented elsewhere and required transfer;
• (iii)  bring the Medical Adviser's comments to the attention of the bed management team (at Raigmore Hospital) and the relevant medical director; and
• (iv)  apologise to Mrs C for the failures this investigation identified.

Summary
Mrs C complained about the way her late mother Mrs A had been treated while in hospital.  Mrs A, who had dementia, was admitted to Borders General Hospital on 20 November and discharged on 4 December 2012.  She was readmitted on 6 December and then discharged again on 17 December 2012.  Mrs C was concerned about aspects of her mother's treatment while in hospital and that she was discharged too soon.  She felt that Mrs A had been treated poorly because of her cognitive impairment.  I sought independent expert advice from a nursing adviser and a medical adviser.  I did not find that Mrs C had been deliberately discriminated against because of her dementia.  However, my investigation identified a significant number of failings in her care, many of which related to a failure to provide appropriate care and support to someone with cognitive impairment or to follow the legislation that provides protection for someone with cognitive impairment who requires medical treatment.  As a result of these failings, it is likely that, taken together, the failings were such that Mrs A's rights as an NHS patient and a dementia patient were infringed.

Care seemed to be poorly led and coordinated.  There was no evidence of a full care plan and, despite the fact that she had been admitted to the hospital because of a fall and had five falls during her stay, there was no completed falls assessments in the clinical records or any evidence of a falls prevention plan.  There was limited evidence of the involvement of medical staff and communication with the family was sporadic and poor.  Pain and nutritional assessments were inadequate.  There was also a specific incident of which I am critical when Mrs A required but was not provided with adequate pain relief and this meant her journey to the care home on 4 December was very uncomfortable.  While the report identifies a number of medical and nursing failures, I did not uphold a complaint about physiotherapy and occupational therapy.  There was evidence in the records of appropriate physiotherapy involvement and while I am critical that an occupational therapy assessment was only carried out after prompting by the care home, I found that overall care in these areas had been reasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) monitor practice to ensure national dementia standards are being met including specifically that the presence of cognitive impairment is given due regard in the planning of care, and that the level of observation, supervision and provision of support provided to people with delirium and/or dementia is appropriate for their impaired capacity;
• (ii) ensure that staff comply with adults with incapacity legislation, in particular completing section 47 certificates and accompanying care plans;
• (iii) take steps to ensure communication with relatives and carers of patients with cognitive impairment is proactive and systematic;
• (iv)  ensure that falls prevention clinical practice is administered within the Hospital in line with recognised good practice and Board policy;
• (v) ensure that nutritional care is carried out in line with national policy and that nutritional care plans are developed, implemented and evaluated for each patient as appropriate;
• (vi) explore all options to implement an observational pain assessment tool for use with patients with cognitive impairment;
• (vii) undertake an audit of record-keeping in wards caring for patients with cognitive impairment to ensure compliance with record-keeping guidelines and a reasonable standard of practice;
• (viii) review their discharge policy to ensure:  its continued relevance in light of the failings arising from this case; it meets the needs of people with cognitive impairment and the need to fully involve the family in decision-making; a more systematic approach to discharge planning; and pre-discharge assessments are clearly identified at an early stage and carried out within a reasonable time to inform follow-up care;
• (ix) ensure the failures identified are raised as part of the annual appraisal process of relevant staff and address any training needs particularly in relation to falls prevention and adults with incapacity legislation; and
• (x) apologise to Mrs C for the failures this investigation identified.

Summary
Mrs C complained that her late husband (Mr A) was not provided with appropriate care and treatment after he was admitted to Dumfries and Galloway Royal Infirmary.  Mr A was admitted with a suspected stroke but developed severe diarrhoea.  His condition deteriorated significantly over the next few days and he developed a number of other symptoms, including problems with his oxygen levels, his heart and his breathing.  He was transferred to intensive care, but died some four weeks after he was admitted.  Mrs C said that although she was very concerned about her husband's condition, he was not seen by a consultant until about a week after he was admitted.  She repeatedly raised her concerns with staff, but felt these were dismissed.  Mrs C felt it took too long to recognise that Mr A had had a heart attack, and said he lost all his dignity while in hospital and suffered unnecessarily.

The board met with Mrs C some months after she first complained, and wrote two months after that to further clarify what had been said, acknowledging her concerns that the heart attack was not diagnosed sooner.  They said, however, that they hoped she was reassured that they had carried out a series of appropriate tests to diagnose Mr A's condition, although with hindsight this could have been done more quickly.  They apologised for Mrs C's experience.

The records did not show what was said at the meeting, but there were statements from two doctors within the complaints papers.  Both acknowledged that it was unfortunate that Mr A was not reviewed earlier, and that there were issues with availability of consultants.  I also took independent advice on the complaint from a consultant cardiologist, who said that Mr A died following a critical illness, which culminated in multi-organ failure.  Although he already had underlying health conditions, there was evidence of a recent heart attack and a related life-threatening condition.  My adviser identified a number of failings in Mr A's clinical care, including that the heart attack could have been diagnosed sooner, fluid therapy was not appropriately managed, and medical records were inadequate, with electrocardiogram (heart function monitor) results that were not properly labelled and that did not appear to have been compared in sequence.  This meant that Mr A was not adequately reviewed and his heart problems not considered early enough - critical omissions when planning his treatment.

I accepted this advice and upheld Mrs C's complaint.  I found that Mr A was not reviewed by a cardiac consultant early enough, and was placed on inappropriate fluid therapy, which compromised his treatment and meant that his care fell below a reasonable standard.  I also found the board's complaints handling and apology inadequate, given that two senior members of board staff identified failures in Mr A's care, and that I saw no evidence of the board taking action to improve procedures as a result of Mrs C's complaint.

Redress and recommendations
I recommended that the Board:

• (i)  carry out a critical incident review into Mr A's death;
• (ii)  remind all staff of the importance of contemporaneous, accurate and full medical notes;
• (iii)  provide evidence that the complaint investigation has been reviewed, to establish why failings by the Board identified by staff members were not acted upon;
• (iv)  remind all staff of the importance of discussing completion of the decision to designate a patient as 'not for resuscitation' with either the patient or appropriate family members;
• (v)  provide evidence that the full report has been discussed by the Board at the first meeting following its publication; and
• (vi)  apologise unreservedly to Mrs C for the failings identified in this report.

Summary
Ms C complained to us on behalf of her client (Mr A) that doctors did not reasonably diagnose that his late wife (Mrs A) had cancer.  In late 2012, Mrs A had breast cancer surgery, during which an extremely large high-grade tumour was removed.  She contacted the practice some seven months later complaining of back pain and spasms.  She also then developed a wheeze and cough.  Between 29 July 2013 and 19 August 2013 she had four telephone consultations with three GPs at the practice, who prescribed and adjusted pain relief medication, and later provided Mrs A with an inhaler.  The day after the last consultation, she contacted NHS 24 because she was having problems breathing.  They arranged for an out-of-hours doctor to visit, who diagnosed pneumonia and said Mrs A should contact her GP.  She did this the same day, and saw another GP from her practice, who referred her straight to hospital because of her history of breast cancer.  She was found to have cancerous growths and a build-up of fluid in her chest.  She was admitted to hospital but died before cancer treatment could be started.

When Mr A complained to the practice they concluded that they did not identify early enough that Mrs A was as unwell as she was, and that it would have been better if she had been more fully assessed.  They said that this might have been partly due to a breakdown in communications, apologised for the standard of care provided and said that they would carry out a Serious Event Analysis (SEA) of Mrs A's case.  Mr A was not satisfied with this, and took the complaint further, latterly with the help of Ms C.  The final outcome was that although the practice agreed that with hindsight things could have been done better, they said that they had found nothing that needed remedy.

I took independent advice from one of my medical advisers, who is a GP.  She said that the medical histories taken during the telephone consultations were sparse and that Mrs A's clinical history should have made doctors suspect that the cancer might have come back.  The surgeon had told the practice that it was not possible to say whether surgery had achieved a long term cure.  Given all the circumstances, my adviser said that Mrs A should have been physically assessed at the time of the first call, and certainly when the pain did not resolve after painkillers were provided.  My adviser had several concerns about the lack of assessment before prescribing treatments, and these are detailed in my report.  She also pointed out although that the SEA report showed some evidence of reflection on and learning from Mrs A's case, the practice also appeared to have suggested that some of the responsibility lay with Mrs A for not explaining just how much pain she was in.

I upheld Ms C's complaint, as I found that a combination of errors led to an unreasonable delay in diagnosing Mrs A's condition.  She should have been seen face-to-face and assessed much earlier, and elements of her care fell below General Medical Council standards.  Although the practice accepted that they did not physically assess her early enough and have introduced a new telephone protocol, my adviser identified some other serious failings, especially around prescribing medication without adequate knowledge of the patient's health.  I was also concerned that in handling the complaint the practice appeared to ascribe some of the blame to Mrs A, which suggests to me that they had not fully accepted that their handling of her case was not of a reasonable standard.  They also appeared to minimise fault on the part of the doctors, and I found the tone of some of their letters inappropriate.

Redress and recommendations
I recommended that the Practice:

• (i)  apologise to Mr A for the failure to identify the recurrence of Mrs A's cancer;
• (ii)  ensure that this complaint is discussed during the next annual appraisals of GP 1, GP 2 and GP 3;
• (iii)  raise awareness amongst all doctors at the Practice of the signs and symptoms of cancer recurrence; and
• (iv)  refer this case to the Board for further discussion with their clinical support group to avoid a recurrence of similar events in future.

Overview
The complainant (Mrs C) complained to Western Isles NHS Board (the Board) that a locum consultant gynaecologist (Consultant 1) had not carried out the operation originally agreed between her and her consultant gynaecologist (Consultant 2).  She was further concerned that Consultant 1 incorrectly told her the agreed operation had been carried out; she later discovered it had not been.

Mrs C also complained that she had been given inaccurate information about her post-operative complications.

Specific complaints and conclusions

The complaints which have been investigated are that:

• Consultant 1 unreasonably failed to carry out a full hysterectomy as agreed with Consultant 2 (upheld);
• Consultant 1 provided inaccurate information about the procedure he had carried out (upheld); and
• the Board provided an inadequate explanation concerning the complications which arose during Mrs C's surgery (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in complaint (a); in particular, that they did not afford her the opportunity to have the operation she had previously agreed with Consultant 2;
• ensure that the comments of the Adviser, in relation to the issue of consent; are brought to the attention of the relevant staff;
• review the procedures for arranging locum surgical cover, so as to ensure that the locum has the requisite surgical skills and expertise;
• apologise to Mrs C for the failing identified in complaint (b), that Consultant 1 provided her with incorrect information about her operation;
• review their current significant adverse event guidance in light of the Adviser's concerns detailed in this report and share the Adviser's comments with the relevant staff; and
• ensure they have a clear policy in place concerning the transfer of patients from one consultant's care to another.

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

Overview
The complainant (Mr C) complained to Ayrshire and Arran NHS Board (the Board) about the care and treatment he received at Crosshouse Hospital, Kilmarnock (the Hospital) in connection with surgery for the removal of duct stones.

Specific complaints and conclusions
The complaints which have been investigated are that the Board unreasonably failed to:

• obtain consent for the specific procedure that was carried out on Mr C (upheld); and
• remove duct stones at the time of Mr C's first operation (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr C for the failings identified in complaint (a) of this report;
• provide evidence of the action taken as referred to paragraph 16 of this report;
• carry out a significant event analysis of what happened in Mr C's case and report the findings to my office;
• provide evidence that they have addressed the issues of (i) consent being obtained by medical staff not competent to carry out the surgical procedure the patient is being consented for; and (ii) obtaining written consent on occasions other than the day of the patient's surgery;
• ensure that the comments of the advisers are brought to the attention of the relevant staff;
• issue a written apology to Mr C for the failings identified in complaint (b) of this report; and
• provide evidence of the action taken to address the failings identified in respect of the removal of Mr C's residual right sublingual gland.

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

Overview
The complainant (Mr C) brought this complaint to the SPSO on 26 April 2013 on behalf of the owners of a nightclub, (Company A).  He complained that Company A had been forced to spend a large amount of money on sound proofing and noise reduction measures at the nightclub because South Ayrshire Council (the Council) unreasonably imposed a potentially unenforceable planning condition when they granted consent for a planning application in 2000.  The planning permission was for flats, to be built adjacent to the nightclub, which were built in 2001.  Mr C has raised concerns that the flats were built without appropriate sound attenuation measures in their construction and that this led to complaints from residents, which ultimately meant that Company A had to make substantial changes to their property to allow them to continue operating as a nightclub.

Specific complaint and conclusion
The complaint which has been investigated is that the Council unreasonably imposed a potentially unenforceable planning condition on planning application X (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• cover the full cost of works which Company A have incurred in undertaking sound proofing and noise reduction measures at their nightclub, based on Company A providing appropriate invoices; and
• apologise to Company A for the time, effort and expense which has resulted from the Council's maladministration.

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

Overview
The complainant (Ms C) raised concerns that her late mother (Mrs A) developed lithium toxicity during her admission to Pavilion 2, Ayrshire Central Hospital, as a result of inadequate fluid intake.  Ms C was also concerned that Mrs A had a heavy fall during her admission and suffered significant injuries.

Specific complaints and conclusions
The complaints which have been investigated are that Ayrshire and Arran NHS Board (the Board):

• did not reasonably ensure that fluid intake was adequate (upheld); and
• did not take reasonable steps to ensure the patient's physical safety (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• identify and address any staff training needs in relation to lithium toxicity;
• remind nursing staff that action is required to address low fluid intake when the intake for a lithium patient falls below 1.2 litres;
• issue a written apology to Ms C, acknowledging the failings identified in this report;
• provide his office with a copy of the six-monthly review of the measures set out in the Quality Improvement Plan for improving falls assessments, fluid intake monitoring and record-keeping.  If the measures of effectiveness set out in the plan were not met, the Board should explain what further action will be taken;
• provide refresher training for staff involved in Mrs A's care on the requirements of the Falls Management Guideline for In-Patients; and
• raise the findings of his investigation with the staff responsible for Mrs A's care, for reflection as part of their next performance appraisal.

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

Overview
The complainant (Mr C) raised concerns about the treatment his late daughter (Ms A) received from Ayrshire and Arran NHS Board (the Board).  Ms A had attended University Hospital Crosshouse (the Hospital)'s Emergency Department and was admitted, but sadly passed away a couple of days later.  Mr C complained to my office about the clinical and nursing care his daughter had received and also the Board's handling of the complaint he and his wife (Mrs C) made to them.

Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:

• take appropriate steps to assess and treat Ms A's sepsis (upheld);
• provide appropriate nursing care for Ms A (upheld); and
• handle Mr C's complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their protocols for identification of sepsis, identification of deteriorating patients and sepsis management and audit their performance using the Scottish Patient Safety Programme;
• reduce the time to consultant review for on-call teams managing critical illness, in line with the relevant Royal College of Physicians' Guidance;
• improve access to intensive care advice for on-call clinical teams;
• use this case in educational / mortality review meetings in the emergency department and medical units;
• ensure this case will be included in the consultants' next appraisal;
• carry out a Significant Event Analysis, with reflective commentary, of the care and treatment provided to Ms A and the handling of Mr and Mrs C's complaint; and
• apologise to Mr and Mrs C in writing for the failings identified in this report.

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