West of Scotland

  • Report no:
    201508849
  • Date:
    August 2016
  • Body:
    Lothian NHS Board
  • Sector:
    Health

Summary
Ms C complained about the care and treatment provided to her late daughter (Miss A) by the board's Intensive Home Treatment Team (IHTT), and about the way in which Miss A was discharged from their care.  Miss A, who had a history of low mood and self-harm, was referred to the IHTT following an attempted overdose.  She was discharged from their care after around six weeks and died at home a week later, having completed suicide.

Ms C complained about a lack of continuity of care, noting in particular the absence of a key worker for Miss A.  I took independent medical advice from a consultant psychiatrist, who noted that in a crisis service such as the IHTT, it is difficult to avoid patients being seen by a number of different staff.  However, the adviser considered that much more could have been done to enhance the continuity of care provided to Miss A.  The IHTT policy indicates that every service user will be allocated a named worker and that complex case discussions will take place, but neither appears to have happened in Miss A's case. Ms C also complained about a lack of clarity surrounding Miss A's diagnosis. I was advised that the sharing of Miss A's diagnosis was reasonably consistent throughout, although differing terminology was used.  However, I noted that there was some ongoing uncertainty surrounding the extent of Miss A's unstable personality traits, which might have benefited from a psychological opinion.  The IHTT policy indicates that a psychological opinion can be sought within the IHTT but I found no evidence of this having been considered.  I was also advised that the IHTT policy might benefit from being updated to define clearly the role of medical staff in diagnosing patients.  I upheld this complaint.

Ms C complained about the appropriateness of Miss A's discharge from the IHTT, noting that she had ongoing suicidal thoughts.  I was advised that the decision to discharge Miss A was not in itself unreasonable, as the IHTT provide short-term input to patients in crisis and that chronic risk over the long-term is not managed in this setting.  However, I was advised that the process followed in discharging Miss A was unreasonable.  I found little evidence of discharge planning and no indication that plans were discussed with Miss A.  I was particularly concerned that there was a lack of evidence of medical input into Miss A's discharge. Ms C also expressed unhappiness with the follow-up plan that was put in place and said that Miss A felt lost and abandoned.  I agreed that the follow-up arrangements were not sufficiently robust.  Miss A was discharged into the care of her GP, with the noted involvement of a private counsellor she was seeing and the provision of crisis service contacts.  I concluded that Miss A should have been referred for psychiatric follow-up.  I was concerned that Miss A was discharged entirely from the board's care on the basis of her private counselling, when no steps were taken to contact the private counsellor to find out what was being offered in terms of follow-up.  I upheld this complaint.

Miss A attended A&E on three occasions while under the care of the IHTT, following further suicide attempts.  Ms C complained that during these attendances, Miss A was not afforded sufficient privacy and dignity in her distressed states.  She also complained that there was a four hour delay in Miss A receiving a mental health assessment and did not consider that enough had been done to ensure Miss A was supported following discharge from A&E.

I took independent medical advice from a consultant in emergency medicine.  I was advised that Miss A had been treated in line with normal practice in a busy A&E department and I could not conclude that there was a failure to afford her adequate privacy or dignity.  I was advised that a four hour wait is not unreasonable where a patient has taken an overdose and a detailed medical assessment is required prior to mental health assessment.  I was critical, however, that it was not documented who was accompanying Miss A and assuming responsibility for her when she was discharged following her third attendance.  In addition, I was advised that a mental health assessment form was only completed for Miss A's first attendance.  While I was assured that she was appropriately assessed, and that this omission made no material difference to the care she received, I concluded that it would be good practice for this form to be completed in every instance.  On balance I did not uphold this complaint but I made some recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

  • support the IHTT to implement and adhere to the IHTT Operational Policy, specifically with regard to named workers and facilitating complex case discussions;
  • consider revising the IHTT Operational Policy to include a description of the roles of medical staff (including different grades of medical staff) within the IHTT;
  • apologise to Ms C for the failings identified in the care and treatment provided to Miss A;
  • review the discharge planning process in the IHTT, taking account of the considerations highlighted in this report;
  • review the IHTT Operational Policy, setting out clear guidance for when patients should be seen by medical staff;
  • provide detailed evidence of all action taken to implement the AER (adverse event review) recommendations;
  • apologise to Ms C for the identified failings in the process for discharging Miss A and planning her follow-up care;
  • consider introducing a system whereby completion of the A&E mental health risk assessment form is mandatory for all mental health patients; and
  • highlight to A&E staff that it is good practice for them to document who vulnerable patients are accompanied by on discharge, and whether the accompanying persons are happy to accept responsibility for patient safety.
  • Report no:
    201507563
  • Date:
    July 2016
  • Body:
    Lothian NHS Board
  • Sector:
    Health

Summary
Mr C, who suffered from a hereditary heart condition, had an operation at the Royal Infirmary of Edinburgh to remove a machine implanted in his chest to monitor his heart.  The operation was carried out by a trainee doctor. When the trainee doctor encountered difficulties, he was assisted by a more senior trainee doctor.  Mr C subsequently required a second operation to revise the scar the first procedure had left on his chest.

In investigating, I took independent medical advice from a consultant cardiologist, as well as considering the board's own investigation of the complaint.

Mr C complained the first operation had not been carried out to an appropriate standard.  He said that the experience had been painful and distressing and  believed the correct procedures had not been followed. Mr C believed the trainee doctor performing the surgery had not been competent to do so, noting that the time taken to perform the operation meant he required additional anaesthesia, as his initial dose had worn off.

The board said they had thoroughly reviewed Mr C's treatment. The board said the tools for cauterising the wound to stop bleeding post-surgery had not been available.  Silk stitches had been used instead, but these may have contributed to the poor healing Mr C experienced. The board said the consultant responsible for supervising the operation was available, but had not been present throughout the operation.  The board acknowledged Mr C's experience fell short of what he could have expected.

The adviser said the board had not adequately explored the conflict between the contemporaneous note of the operation and the conclusions reached by the complaint investigation.  The operation note stated cauterisation had been used to stop Mr C's bleeding, but as the complaint investigation acknowledged, this could not have been performed as the equipment was not available at the time.  The adviser said the operation note's inaccuracy had not been properly explored, nor did the note record the difficulties encountered during the surgery. The adviser said it was unreasonable for a trainee doctor to be allowed to perform the surgery unsupervised, as it was not a straightforward procedure.

The adviser added the board did not address the issue of supervision.  Their complaint response gave the impression a consultant had been present at points during the operation.  The available evidence showed no consultant had been present at any point, nor had they been aware Mr C's procedure was being carried out by a trainee doctor.  The adviser also noted Mr C's consent was not properly obtained and that there were inadequate records of the information provided to him prior to surgery.

I found the board failed to investigate Mr C's complaint thoroughly, although they had accepted the standard of treatment received was unacceptable.  I also found they had failed to deal comprehensively with the service failures Mr C experienced.  I am critical of these failings, which resulted in a misleading formal response being provided by the Board and a lack of evidence that adequate steps had been taken to prevent a reoccurrence.

Mr C also complained that the effect of the first operation had not been recognised by the board.  He had stated to the board that his business had suffered severely whilst he was unable to work and that he had been forced to cease trading.  I was critical of the board for failing to address this issue, even though Mr C raised it twice during his complaint.  I considered the board had to address the impact on him of the failure to carry out his surgery in a reasonable fashion.

Redress and recommendations
The Ombudsman recommends that the Board:

  • provide evidence of the actions taken by Doctor 2 to improve their skills and their subsequent appraisals;
  • provide evidence that Doctor 2 has continued to practice without significant subsequent complaints or concerns being raised;
  • provide evidence that their policy for the supervision of trainees during surgical procedures has been reviewed;
  • review the consent forms used for this type of surgery to ensure they accurately reflect the potential complications;
  • remind all staff of the importance of documenting consent fully and accurately; and
  • provide Mr C with a comprehensive and patient centred response to the issues he has raised concerning the impact of the surgeries on his ability to work and his finances.
  • Report no:
    201406803
  • Date:
    March 2016
  • Body:
    Golden Jubilee National Hospital
  • Sector:
    Health

Summary
Mrs C attended the Golden Jubilee Hospital for a modified Brostrom procedure (ligament repair) on her ankle.  Following surgery, tests showed she had severe nerve damage. This was believed to have been caused by the popliteal nerve block anaesthesia (an injection of local anaesthetic near the nerves that go to the area being operated on) that she received for the surgical procedure.  Mrs C complained that she was not informed the nerve block would be carried out or about the risks. She said that she did not see the consultant anaesthetist before the procedure.  Mrs C complained that her injury was caused during the procedure and that staff failed to carry out the procedure to a reasonable standard.  She said that the nerve damage had had an enormous impact on her life.

As part of my investigation, I obtained independent advice from a medical adviser who is a consultant anaesthetist.  The adviser said there was no documented evidence in Mrs C's medical records of a discussion about the surgical procedure and its possible side effects, whether common but minor side effects, or rare but serious ones.  The adviser noted that the General Medical Council (GMC) guidance on consent issues was clear that patients must be told about recognised serious adverse outcomes, even if they are rare.  Nerve damage was a recognised side effect of techniques such as the nerve block so, even though the risk of permanent nerve damage was very rare, I considered it a failing that Mrs C was not warned about it.  The limited interaction with Mrs C before her operation meant that staff did not obtain her informed consent and I upheld her complaint.  I was concerned that these failings may have been caused by the pressures on the service.  I recommended the board conducted a review to ensure enough time was spent with patients before procedures to obtain consent properly.

Regarding Mrs C's complaint that the procedure was not carried out properly, the adviser noted that there was no record taken at the time of the procedure of the anaesthetist's technique and practice.  This was a significant failing.  However, the adviser said the technique reported later (although without much detail) gave an indication of a reasonable technique by an experienced clinician.  I agreed with the advice that there was limited documentary evidence to indicate that the practice and technique was of a reasonable standard.  Although there was no clear evidence that Mrs C's injury was caused during the procedure due to a failure by staff, the lack of contemporary record-keeping meant there was no assurance of carefully considered practice and technique.  On balance, I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

  • bring the failings (related to explaining the risks of a popliteal nerve block anaesthesia) to the attention of relevant staff and ensure they are raised as part of their annual appraisal;
  • review the service to ensure there is sufficient time to properly obtain (and document) consent for procedures;
  • bring the record-keeping failings (related to carrying out the procedure in an appropriate manner) to the attention of relevant staff and ensure they are raised as part of their annual appraisal; and
  • apologise to Mrs C for the failures my investigation identified.
  • Report no:
    201407663
  • Date:
    March 2016
  • Body:
    Business Stream
  • Sector:
    Water

Summary
Mr C complained on behalf of a business that had had an account with Business Stream since 2006.  The average water usage was reasonably consistent but a meter reading taken in April 2010 showed what the meter reader considered to be a disproportionately high reading.  The meter reader contacted Business Stream to alert them to this, and confirmed that there was no evidence of a leak at the meter.  In May 2010, the business received a bill from Business Stream which they queried as they considered it to be very high.  The business believed a leak had been caused by Scottish Water carrying out work in the area, but Scottish Water had no record of work being carried out.  Although a Business Stream complaints response to Mr C in 2015 referred to a repair having taken place in May 2010, the only activity recorded on the date in question was the new meter reading.

Mr C said that Business Stream's failure to make his business aware that a leak had been repaired meant that they were unable to apply for a burst allowance (a burst allowance is made in cases where a leak has been caused by Scottish Water's actions or on pipework for which they are responsible or in cases where the customer can show that the leaked water did not drain into Scottish Water's sewers).  However, I found that there was sufficient evidence that the business were aware of a leak in May 2010 and Business Stream had given them information about how to apply for a burst allowance in August of that year.  Business Stream had also applied to Scottish Water for a burst allowance for the business (which was refused as Scottish Water had no record of a leak).  I therefore did not uphold this complaint.

I did, however, find that Business Stream’s failure to take two meter readings in the 12 months before the high bill was issued meant that it was a full 12 months until the high usage could be identified.  Business Stream’s metering policy acknowledges the water industry market code which requires that there are two meter readings taken a year.  Business Stream noted in their response to us that they had made repeated attempts to read the meter but were unable to access it.  Whilst problems in accessing the business’s meter during other time periods was recorded by Business Stream, I found no evidence that the business were contacted by Business Stream about meter access during the period in question.

Although I did not uphold this aspect of the complaint, I did make some recommendations which reflect the significant injustice that has arisen as a result of the failure by Business Stream to take the required number of meter readings.

The events in question happened in 2010, and the business and Mr C had raised their concerns with Business Stream over a number of years.  These appear to have been largely treated as enquiries or billing disputes until October 2014, when a complaint was logged by Business Stream.  Business Stream acknowledged the complaint on the day it arrived, but it took until March 2015 to receive a response.  Not only did I find that the complaints process could have been started earlier to reduce some of the back and forth correspondence, I also found that once Business Stream treated Mr C’s concerns as a formal complaint, they failed to meet the targets that they set for themselves.  I was critical of Business Stream’s handling of this matter, so I upheld this aspect of Mr C’s complaint and made some recommendations.

Redress and recommendations
The Ombudsman recommends that Business Stream:

  • credit the Business with an amount equivalent to six months of the inflated water usage and waste water charges over the period of the spike in usage;
  • take steps, in line with their metering policy to ensure two actual reads are submitted to the CMA each year;
  • apologise to Mr C for their poor handling of his complaint; and
  • remind their complaints handling staff of the importance of keeping complainants updated throughout the course of their investigations.
  • Report no:
    201403146
  • Date:
    October 2015
  • Body:
    Lothian NHS Board
  • Sector:
    Health

Summary
Mr A was elderly and had several serious health problems, including a form of dementia.  He was admitted to the Royal Edinburgh Hospital from his nursing home due to worsening behavioural problems, including agitation and aggression.  His mental health assessment showed that he lacked awareness and insight into his problems, and had trouble with communication.  This, plus his aggression, meant that he was a risk to himself and other people.

Mr A was mobile with the help of a walking stick when he was admitted to hospital.  He fell two days later and suffered bruising, then fell again a few days later, and broke his hip.  He was transferred for surgery but died two days after the operation.

His daughter (Mrs C) believed that Mr A's fall risk had been poorly assessed when he was admitted, and that he was not properly cared for after the first fall so the second fall was not prevented.  She was concerned that he was over-sedated and not eating or drinking enough, and that the management of his diabetes was inadequate.  She also felt Mr A's aggression had not been handled well and that he was blamed for his behaviour, when it was actually the result of his illness.

I obtained independent advice from a nursing adviser, who noted that the board's policy is to complete a falls risk assessment for all elderly patients and to review the patient's falls care plan if they fall.  The board's complaint investigation report said that this was all done, but my adviser found no evidence to support this and considered that the standard of record-keeping and falls prevention practice was poor overall.  I agreed with this view and, therefore, upheld the complaint and made recommendations.

Regarding Mrs C's complaint about sedation, my adviser said that the appropriate medication and dosage was prescribed and that quick action was taken when adverse effects were noted.  My adviser also considered that the board's response letter was balanced and did not blame Mr A for his behaviour.

However, the advice I received was critical overall of the standard of nursing provided to Mr A.  The record-keeping was inadequate and did not include care plans for Mr A's personal care or communication difficulties.  There was also a significant failure to monitor Mr A's blood glucose levels appropriately and a failure to adequately monitor his nutritional intake.  I noted that the board's complaint response states that blood glucose levels were not monitored following Mr A's admission and I was critical of their failure to act on this.  I upheld the complaint and made several recommendations.

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board:

  • remind all staff that a falls risk assessment is a requirement on admission of an elderly patient;
  • review the complaint investigation to establish why statements about Mr A's care not supported by the clinical record, were included in their formal response;
  • review their admission procedures for elderly patients to ensure that a Malnutrition Universal Screening Tool assessment is recorded;
  • remind all staff involved in Mr A's care of the importance of regular and accurate blood glucose monitoring for diabetic patients;
  • remind all staff involved in Mr A's care of the importance of accurate and comprehensive care plans, which meet all a patient's needs; and
  • apologise to Mr A's family for the failures identified in this report.

 

  • Report no:
    201305461
  • Date:
    September 2015
  • Body:
    Lothian NHS Board
  • Sector:
    Health

Summary
Mrs A was transferred from Victoria Hospital, Kirkcaldy, which is the responsibility of Fife NHS Board, to the Royal Infirmary of Edinburgh for heart surgery.  Following one postponement in mid-December, the operation went ahead on 21 December 2012.  Mrs A's niece (Mrs C) said that two days after the operation, her aunt was having a blood transfusion shortly after which she began to very rapidly decline.  Mrs A was admitted to intensive care and died on 26 December 2012.  The cause of Mrs A's death was recorded as multi-organ failure due to sepsis of unknown source in association with recent prosthetic aortic valve replacement and known ischaemic heart disease (a condition that affects the supply of blood to the heart).  Mrs C complained that her aunt did not receive appropriate care and treatment from Lothian NHS Board.

In investigating this complaint, I took independent clinical advice from a cardiothoracic surgeon (specialising in chest, heart and lung surgery).  The advice I received was that the heart surgery appeared to have been performed to a high standard, and Mrs A's initial recovery was good.  Following a routine observation, Mrs A was recommended to have a blood transfusion.  Her condition quickly deteriorated, and the board said that staff suspected a transfusion reaction and implemented their procedures for this.  My adviser said that all teams reacted appropriately and promptly in response to Mrs A's condition.

Tests were taken to determine the cause of Mrs A's change in condition and I am satisfied that the blood Mrs A received was not contaminated.  Her deterioration was coincidental with her developing a bacteria entering into her blood stream in association with sudden acute liver failure.  However, I understand that it must have been very distressing for Mrs A's family to witness her sudden deterioration given the early signs that her heart surgery had been successful.

My investigation identified a number of areas that I am critical of.  My adviser told me that communication between the two hospitals treating Mrs A should have been better given her status as a high-risk patient with other pre-existing medical conditions and a history of previous heart surgery.  Related to this, given Mrs A's case was a high-risk and complex case, this should have been discussed at a pre-operative multi-disciplinary team meeting, which did not happen – the board said that when Mrs A was transferred to the Royal Infirmary she was fit for surgery and there were no alternative treatments to discuss.

My adviser noted that some documentation was not completed appropriately, particularly around consent for the procedure.  Following Mrs A's death, there is no evidence that her GP was notified, as should have happened.  I also acknowledge that there was an early retraction of Mrs A's death certificate which, according to my adviser, had been inappropriately completed by a junior doctor.  I recognise the additional distress that this would have caused Mrs A's family.

Finally, during the course of my investigation I identified that there was a positive result from an umbilical (navel) swab taken on 12 December 2012, the day of the initial scheduled operation, which may have been the source of the subsequent bacteraemia (the presence of bacteria in the blood) and septicaemia responsible for Mrs A's death.  My adviser said that although the positive result was acted upon and antibiotics prescribed to Mrs A, it is not apparent that the potential relevance of this positive finding for Mrs A, who was who was due to undergo high-risk re-do cardiac surgery, was fully realised by the cardiac team treating her and whether consideration was given to potentially delaying Mrs A's surgery in view of the risk of the subsequent sepsis.

I made a number of recommendations to address the failings I identified in the care and treatment provided to Mrs A.  I also found that the board's handling of Mrs C's complaint was not reasonable.  There were delays in responding which I accept the board have apologised for, but the apology letter was brief, lacked empathy and did not fully address the reasons for the delay.  I note, however, that process changes have since been implemented so I have not made a recommendation about this.

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i)  ensure that the comments of the Adviser in relation to the issues of consent and proper and accurate record-keeping are brought to the attention of the relevant staff and a review is carried out; 30 November 2015
  • (ii)  ensure the comments of the Adviser in relation to the positive umbilical swab taken from Mrs A on 12 December 2012 are brought to the attention of relevant staff and they reflect on this; 30 November 2015
  • (iii)  apologise to Mrs C and the other members of Mrs A's family for the failings identified in complaint (a); and 30 October 2015
  • (iv)  apologise to Mrs C and Mrs A's daughter for the failings identified in the apology letter initially issued to Ms A's family. 30 October 2015

The Ombudsman recommends that the Board and Fife NHS Board:

  • (v) ensure the comments of the Adviser in relation to the lack of clear cardiology referral documentation between Hospital 1 and Hospital 2 are brought to the attention of relevant staff. 30 November 2015

 

  • Report no:
    201404127
  • Date:
    September 2015
  • Body:
    A Medical Practice in the Lothian NHS Board area
  • Sector:
    Health

Summary
After suffering a stroke earlier in the year, Mr A was discharged from a hospital to a Step Down Unit in May 2014.  This is a unit in a nursing home for elderly patients who are fit for discharge from hospital but need further rehabilitation before they can return home.  Following a fall at the unit in early July 2014, Mr A's condition deteriorated.  Over a number of weeks, he developed reduced mobility, reduced food intake and increasing pain.  Mr A's daughter (Miss C) complained that, from the time of his fall until his readmission to hospital in early August, the care and treatment he received from GPs at his medical practice was unreasonable.  She considered that Mr A should have been admitted to hospital earlier, and that it was unreasonable for a GP to suggest that one of the options was not to intervene, but to keep Mr A comfortable in the unit.

I took independent advice from one of my medical advisers who is a GP.  The adviser had a number of concerns about the practice's failure to properly assess Mr A's condition.  She said that the clinical records were sparse and lacked evidence of examination, of thorough clinical assessment, and of thorough assessment of Mr A's pain.

With regard to Mr A's food and fluid intake, she said that records showed that he lost 8.7 kilograms over a two-month period, or 16.5 percent of his body weight.  This was a significant amount and she would have expected a GP to physically examine their patient to rule out any underlying cause for weight loss.  She would also have expected a GP to have either made urgent arrangements for a dietician to assess the patient or to have provided simple food supplements until the dietician could attend.  She noted that, under the Lothian Joint Formulary Guidelines, Mr A should have been given a MUST score ('Malnutrition Universal Screening Tool', British Association for Parenteral and Enteral Nutrition).  As he had lost so much weight, he would have received the maximum MUST score, identifying the necessity of food supplements and regular monitoring.

It was thought that Mr A may have been suffering from dehydration and also possibly have a urine infection.  The adviser considered that the care and treatment for these issues were not reasonable, as there was a delay in prescribing an antibiotic to treat the suspected urinary tract infection and the management plan to deal with the dehydration was not changed despite there being no improvement for weeks.

With regard to the GP's suggestion of not intervening but keeping Mr A comfortable in the unit, the adviser commented that the diagnosis of dehydration and a possible urinary tract infection were both easily treatable.  She added that Mr A was malnourished and losing weight, yet there was no evidence of investigation or examination.  The adviser said that the suggestion of not actively investigating or treating these potentially reversible conditions, in a patient in a unit that aims to rehabilitate patients for home, was not a reasonable standard of care.

My investigation found that the overall care provided to Mr A during the period following his fall until his readmission to hospital was not of a reasonable standard and so I upheld Miss C's complaint and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the Practice:

  • (i)  carry out a further significant event analysis in partnership with their local clinical director.  This should include consideration of:  how they ensure continuity of care for their patients and regular review of those most vulnerable; GP1's suggestion of keeping Mr A comfortable in the Unit, rather than addressing his potentially reversible conditions; the need for good record-keeping and ensuring thorough recording of clinical information in a patient's medical record, so as to assist in continuity of care; and consideration of the Lothian prescribing guidelines for urinary tract infections.
    They should also consider referring this significant event analysis to NHS Education for Scotland for review; 31 December 2015
  • (ii)  familiarise themselves with the MUST scoring and Lothian guidelines for prescribing oral nutritional supplements; 30 October 2015
  • (iii)  take steps to ensure that  other patients they care for in the Unit are receiving adequate treatment for  malnutrition in line with the Lothian guidelines, where appropriate; and 27 November 2015
  • (iv)  issue a written apology to Miss C for the failings identified in this report. 30 October 2015
  • Report no:
    201305392
  • Date:
    July 2015
  • Body:
    Scottish Ambulance Service
  • Sector:
    Health

Summary
Mr A had collapsed at home. He had phoned for an emergency ambulance and explained that he had a condition called idiopathic thrombocytopenic purpura (ITP - a disorder that can lead to excessive bruising and bleeding including bleeding into the brain which can be fatal).  Mr A also had alcohol-related health issues, and was in contact regularly with healthcare services.  When the ambulance arrived at his home, he explained to the paramedic and technician that he suffered from ITP.  After assessing him, the ambulance crew did not transport him to hospital.  The following day he was found dead at home, and ITP was recorded as one of the causes of death. Mrs C, who complained on behalf of Mr A's son, complained that the ambulance crew should have taken Mr A to hospital when they attended, and was concerned they did not do so because of his alcohol-related health issues and the fact that he had previously called for an ambulance on several occasions.  The ambulance service said that from the records, it appeared that Mr A had been observed appropriately, and he had declined hospital treatment.

I took independent medical advice on the complaint from a paramedic adviser, who told me that the assessment of Mr A was not reasonable, as Mr A's symptoms (along with the readings taken at the time and his pre-existing ITP diagnosis) indicated that he needed assessing at hospital, and he should have been advised of this.  The paramedic's statement that reflected on the number of Mr A's previous hospital visits should not have influenced the decision-making as to his treatment on that occasion.

Whilst my adviser recognised that the paramedic should not necessarily have had knowledge of the condition ITP, the records show no sign of them having tried to get more information about it: they should have sought more specialist advice before diagnosing a simple faint and advising Mr A, on that basis, that he did not need to go to hospital.  The advice I received is that the paramedic involved failed a significant number of professional standards, and this led to Mr A being given insufficient information, or a reasonable assessment to make a decision as to whether he should go to hospital.

It is also clear to me that the ambulance service's investigation into what happened was extremely poor.  They appeared to have taken the crew's statements at face value without further investigation, and they failed to recognise the clinical failings and take action to address them.  I upheld the complaint and made a number of recommendations.

Redress and recommendations
The Ombudsman recommends that the Scottish Ambulance Service:

  • (i)  consider the Adviser's comments in relation to the paramedic and ensure they take appropriate action;
  • (ii)  provide evidence they have procedures in place for paramedics to obtain clinical advice when on scene with complex patients;
  • (iii)  inform us of how they intend to improve and monitor record-keeping;
  • (iv)  inform us of how they intend to ensure their investigations into complaints are thorough and robust; and
  • (v)  apologise to Mr A's family.
  • Report no:
    201401793
  • Date:
    July 2015
  • Body:
    Lothian NHS Board
  • Sector:
    Health

Summary
Miss C was suffering from a severe headache with associated flashing lights that was not relieved by painkillers.  Following referrals from her GP she twice attended an out-patient clinic at St John's Hospital where on both occasions she was reviewed by staff and sent home with medication.  She had a computerised tomography scan two days after the second appointment which showed that she had a brain abscess.  She was transferred to another hospital for emergency surgery, followed by another operation to further drain the abscess.  Miss C raised a number of concerns about the care and treatment she received while attending St John's Hospital, in particular, that the delay in undertaking investigations necessary to diagnose her condition may have led to a more serious outcome and unnecessary prolonged pain and distress.

When Miss C was transferred back to St John's Hospital, she was unhappy with the care she received, in particular the attitude of staff on the ward.  Miss C also complained to us about the delay in diagnosing her condition and the way the board handled her complaint.

I took independent advice from a general medical adviser and a senior nursing adviser.  On the initial diagnosis of Miss C's condition, my medical adviser said that there were sufficient red flag symptoms for Miss C's condition, which was deteriorating over time, to prompt clinicians to investigate further.  Although it is not possible to know if an earlier operation would have improved the outcome for Miss C, I found that the board failed to give her the care and treatment she could have reasonably expected.  I found that in terms of infection control on the ward, there was an unreasonable level of uncertainty from medical staff.  I also found that there was inadequate communication with Miss C and her family.  There had also been errors in relation to one of Miss C's prescriptions and her discharge medication which, whilst my medical adviser said would not have caused any harm, further reduced the confidence of Miss C in the ability of the ward to care for her.  I am also critical that whilst the board apologised, they did not explain how these errors occurred in the first place.  During my investigation, the board also failed to send copies of information sent by them to Miss C's GP. I was also critical of this, as this was relevant information given that Miss C also complained about poor communication between the board and her GP following her discharge from hospital.

In terms of the nursing care she received, my nursing adviser said that whilst there are notes documenting regular interaction between nursing staff and Miss C, some of the notes were poorly completed, so I have concerns about record-keeping.  There was also a breach in nursing protocol in relation to the disposal of a used syringe.  The board has accepted that this protocol had been breached and has assured us that action will be taken to address this.

Although there were some aspects of the board's complaints handling that could have been better, on balance I considered that Miss C received a reasonable level of service in this regard so did not uphold her complaint about the way her complaint was dealt with.

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i)  apologise to Miss C for the failings identified in this complaint;
  • (ii)  report back to the Ombudsman on the outcome of the review of the discharge prescribing and drug ordering procedures at ward level and on any action taken to prevent similar errors occurring in the future;
  • (iii)  remind nursing staff of the need to maintain full and accurate nursing records in line with NMC guidance;
  • (iv)  explain how they will monitor compliance to protocols and ongoing improvements in relation to the safe disposal of clinical waste;
  • (v)  report back on the outcome of the review of infection control procedures to evidence that learning and improvement has occurred; and
  • (vi)  report back to the Ombudsman on the action taken as a result of this case in relation to communication to improve the service provided.
  • Report no:
    201403330
  • Date:
    August 2015
  • Body:
    Scottish Prison Service
  • Sector:
    Scottish Government and Devolved Administration

Summary
Mr C complained about a prison officer inappropriately giving him a pen, which Mr C swallowed the next day, causing injury.  Mr C also complained about the length of time it took for his complaint about this to be dealt with.  I upheld both complaints and made several recommendations to the Scottish Prison Service (SPS) to address the failings in this case and prevent similar situations arising.

I decided to issue a public report on this case as my office has previously investigated and upheld a number of Mr C's complaints.  The report lists the upheld cases from August 2013 to date.  I accept that Mr C presents many challenges in terms of his care, however, I have grown increasingly concerned by the number of complaints from him which this office has upheld.  This has raised concerns of systemic failure in the way that the SPS are managing Mr C and investigating his concerns.  I also considered that Mr C had suffered a significant personal injustice in this case.

Mr C was in a separation and reintegration unit and being managed under a process which is used for handling prisoners who are at risk of suicide or self-harm.  He had repeatedly harmed himself and as a result of this was allowed no items in his cell.  At the time of the incident, Mr C was judged to be at high risk.  SPS staff were to observe him at 15 minute intervals and he was only permitted to wear anti-ligature clothing (clothing specially designed to reduce the potential for self-harm).  That day, Mr C was given a self-representation form in relation to a review of the application of a prison rule.  Although the condition that he was to have no items in use in his cell was in place, Mr C was provided with a pen to complete the form.  Mr C returned the form but kept the pen which he swallowed the next day.  I understand that this caused an internal perforation and he needed surgery to retrieve the pen and repair the damage.

The SPS position is that the pen was provided to Mr C in good faith as he needed it to complete the form.  I note their comments on there being scope to work slightly outwith the care plan conditions and that management considered that with their substantial knowledge of Mr C, this was an instance where staff were able to do so.  I did not agree that providing Mr C with a pen represented working slightly outwith the care plan.  While I accept that the form needed to be completed, I did not find that sufficient account was taken of the condition that no items were permitted when providing him with the pen.

The SPS were also unable to provide copies of the relevant care documentation that was in place on the day of the incident.  These records form an important part of Mr C's case history and I find it concerning that they appear to have gone missing and I am critical of this.  I did, however, accept the SPS's position that the conditions were unchanged from care documents dated three weeks earlier.

I am also concerned that there appears to have been no attempt to retrieve the pen after Mr C had finished using it and that this was not explored by the SPS during their investigation.  Similarly, there appears to have been no attempt to investigate Mr C's complaint that the prison officer made inappropriate comments when providing the pen.  This serious allegation is against the principles of the care process that was in place and I would have expected this to be fully investigated by the SPS at the time.

Taking my concerns about this case in to account alongside the complaints already upheld for Mr C, I have made additional recommendations to address the wider issues in managing his care while he remains in prison.  This related to the new role of Independent Prison Monitors, who help ensure prisoners' human rights are upheld and that life in prison contributes to their rehabilitation.

On the complaints handling aspects, the SPS provided their final response to Mr C well over a year after they received it and I do not consider the length of time Mr C had to wait for a response to be in any way reasonable.  There is no documentary evidence to show that any investigation of Mr C's complaint took place after it was first received or that the prison officer concerned gave Mr C any explanation for the action taken.  I note that the SPS have already noted this failing and that it has been identified as a learning point, however, I am highly critical of the complaint handling in this case.  The lack of documentary evidence of any timely investigation coupled with missing care conditions and complaint paperwork is a matter of some concern.


Redress and recommendations
The Ombudsman recommends that the SPS:

  • (i)  issue a written apology to Mr C for the decision to provide him with a pen when the restrictive ACT 2 Care condition was in place;
  • (ii)  arrange a meeting between the Governor of Mr C's current prison and a senior member of the local NHS Board to discuss our ongoing concerns about his care and to ensure that there is appropriate senior oversight;
  • (iii)  highlight this issue to the new Independent Prison Monitors to ensure that they are aware of our concerns and inform Her Majesty’s Inspectorate of Prisons for Scotland we have asked for specific steps to be taken in relation to Mr C;
  • (iv)  issue a written apology to Mr C for the delay in providing a response to his complaint;
  • (v)  issue a reminder to all staff involved in the handling of this case that all confidential complaints should be investigated and responded to in line with the Prison Rules and associated Staff Guidance on Prisoner Complaints and Disciplinary Appeals; and
  • (vi)  review how paperwork such as complaint forms and ACT 2 Care documents are managed to ensure that important information is not lost.