Health

Summary

C complained that their parent (A) suffered a fall while in hospital. C was concerned that bedrails and falls risk assessments were not appropriately completed prior to A suffering the fall. The board said in their complaint response that both bedrails and falls risk assessments had been carried out appropriately.

We took independent advice from a registered nurse. We found that, from the evidence available to us, the falls and bedrail risk assessments carried out prior to A’s fall were limited and did not inform a comprehensive care plan. The board’s Policy for the Prevention and Management of Adult Inpatients Falling in Hospital Settings did not appear to have been followed. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out appropriate risk assessments and care planning prior to A’s fall. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Falls and bedrails assessments should be completed, in full, within 24 hours of admission and reviewed regularly.

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

C complained about the care and treatment provided by the board to their late parent (A). Additionally, C complained about the nursing care that A received and the boards handling of C's complaint.

We took independent advice from a consultant geriatrician and a senior nurse.

We found the care and treatment of A to be reasonable. We did not uphold the complaint. In relation to nursing care and treatment, we found unreasonable care in a number of areas including but not limited to, failures in wound care, a delay in administering pain relief, shortcomings in the documentation of cannulation attempts, inaccuracies in key nursing documentation, errors in medication administration and inaccuracies in fluid balance.

While communication with C was compassionate and the timeframes were reasonable, the board’s investigation did not fully identify or address several significant failings in A’s care, resulting in an incomplete and unreasonable response to C’s complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings we identified in nursing care and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The board should complete a Datix incident report (if not already completed) and identify appropriate learning action.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaints Handling Procedure. The complaint investigation should fully identify and address failings relevant to the complaint.

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

C complained about the care and treatment provided to their late sibling (A) when they were admitted to A&E, and about the boards out of hours (OOH) service. A was found to have Influenza A and signs of a chest infection. A deteriorated throughout the admission to A&E with increased oxygen requirements and coughing up blood. They then had a cardiac arrest and continued to deteriorate, suffering multiple organ failure. Attempts to stabilise A failed, and A died in hospital. C also complained about the family being pressured to decide whether to have a post-mortem and that a Significant Adverse Event Review (SAER) was not carried out.

The board acknowledged failings around appropriately regular observations not taking place whilst A was in hospital. However, they concluded that the overall care and treatment was reasonable given the circumstances at the time. In addition to this, the board did not uphold C’s complaints regarding the OOH service, the post-mortem, and the SAER.

In respect of the care and treatment provided by the OOH service, we took independent advice from a GP adviser. We found that it was appropriate for a nurse practitioner to review A at the second of two OOH consultations the day before A was admitted to hospital. We found that the assessments and clinical decision-making, based on A’s presentation at the time, were reasonable. We did not uphold this complaint.

In respect of the care and treatment provided when A was in hospital, we took independent advice from a consultant in emergency medicine. We found that appropriate regular observations did not take place. However, we considered that the overall care and treatment provided was reasonable, appropriate tests were carried out and appropriate treatment was provided, given A’s presentation at the time. As such, we did not uphold this complaint.

In respect of whether the family was pressured into making a decision regarding a post-mortem, we found that communication with the family about a post-mortem was reasonable. We considered that we could not know for certain whether the consultant’s notes were an accurate reflection of the discussion, due to the fact that people can have different perceptions of the same conversation. Given this, we did not uphold this complaint.

In respect of whether the board unreasonably failed to carry out a SAER, we found that, although A’s death met the category 1 criteria for a SAER, we noted that health boards have discretion to decide what level of review is appropriate under the Healthcare Improvement Scotland guidance. We felt that the board could have improved their explanation of why they decided not to carry out a SAER and provided feedback around the importance of documenting the decision-making behind whether or not a SAER should be carried out. We concluded that it was not unreasonable for the board not to carry out a SAER. Therefore, we did not uphold this complaint.

Summary

C complained about the care and treatment provided to them by the board when they were admitted to hospitalwith chest pain and respiratory issues. C also complained that the board’s complaint response failed to respond reasonably to C’s concerns.

We took independent advice from a respiratory adviser. We found that it was unreasonable that the board had not performed a pleural aspiration (a procedure to remove fluidfrom the space around the lungs) and had not inserted a chest drain on the day that C’s condition deteriorated in hospital. We upheld this complaint.

We also found that the board’s response to the complaint was unreasonable given that they failed to identify failings in C’s care and treatment in their complaint investigation and failed to carry out a significant adverse event review (SAER). We upheld this complaint, however, we recognised that the board had accepted and apologised for failings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients should receive the necessary care to detect and address the progression in pleural infection, during the normal weekend respiratory cover period. All staff should follow relevant policies and a chest x-ray should be performed after a chest drain insertion.
• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. The board should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.
• The board should undertake SAERs in line with relevant guidance.

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

C complained about the decision of the practice to remove them from their list and about the way that the practice handled their complaint. C had a consultation with a GP at the practice. A few days later C was removed from the practice list.

Practices are entitled to remove patients from their lists in certain circumstances. That said, for a removal to be reasonable, the practice need to be able to demonstrate that they have acted in a way that is consistent with The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 (the 2018 Regulations) and General Medical Council guidance to ending a professional relationship with a patient.

Regarding C’s removal from the practice, we found that the practice did not act in accordance with the 2018 Regulations and the GMC’s guidance. The practice did not provide any contemporaneous written records setting out the reason why no warning was given in this case and the circumstances of the removal. They also did not provide records of the justification for removing C from the practice list for expressing dissatisfaction about the care and treatment provided and the grounds for it not being considered appropriate to provide C with a more specific reason for the removal.

Regarding the handling of C’s complaint, we found that the practice failed to fully investigate and respond to the points of complaint being raised in accordance with the practice’s complaint handling procedure and the NHS Model Complaints Handling Procedure. They also failed to provide C with a copy of the practice’s Public Facing Complaints Handling Procedure. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not acting in accordance with The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 and the GMC’s guidance, for not responding to the points of complaint that C raised and not providing C with a copy of the Practice’s Public Facing Complaints Handling Procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Schedule 6, Part 2 of The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 and the relevant GMC guidance should be followed when considering removing patients from the practice list.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the practice’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. The practice should co-operate with the SPSO when we are investigating a complaint in line with the relevant legislation such as the National Health Service (General Medical Services) (Scotland) Regulations 2018 and the Scottish Public Services Ombudsman Act 2002. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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

C complained about the standard of medical care provided by the board during two attendances at A&E with severe abdominal issues. C was discharged home on both occasions, and shortly after the second discharge, the results of a magnetic resonance scan (MRI) indicated that they had significant abnormalities of the bowel. C was then admitted to hospital for treatment of inflammatory bowel disease.

We took independent advice from consultants in emergency medicine and general medicine. We found that the standard of medical care provided was not reasonable in that recordkeeping and communication was poor, C was misdiagnosed with constipation at the second visit, there was a failure to act on the results of the MRI scan and discuss C’s care with the relevant specialists at the second visit, and there was a delay in treating C and admitting them to hospital. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients’ records should be completed to a reasonable standard and in line with the relevant professional standards. Patients with abnormal test results should be acted on fully and within a reasonable time. Patients with a complex medical history and repeated presentation should have a full differential diagnosis list and all relevant specialists should be consulted with.

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

C complained about the care and treatment provided to their adult sibling (A). A had treatment for breast cancer, was admitted to hospital a short time later and died approximately two weeks after being admitted. C complained about A’s medical and nursing care and treatment in hospital and about the communication with A’s family.

The board said that when A was admitted to hospital, a CT scan (a test that takes detailed pictures of the inside of the body) revealed extensive metastatic disease (disease that has spread from its original location) in A’s liver and bones. Treatment options were discussed with A. A was initially independent after admission to hospital, but A’s condition deteriorated. A was reviewed by an oncologist (a doctor who is a specialist in cancer), and A was deemed too ill for further treatment. The board said that they respected A’s wishes regarding communication with A’s family.

We took independent advice from a specialist doctor in palliative care and a registered nurse. We found that the medical and nursing care and treatment were reasonable, and the board’s communication with A’s family was reasonable. Therefore, we did not uphold C’s complaint.

Summary

C complained that they were inappropriately triaged at A&E because sepsis had not been considered, their symptoms and history were not accurately recorded and medication was not appropriately considered. C felt extremely unwell after taking medication for alopecia, attended the A&E and were triaged within one hour. An allergic reaction was considered, observations were taken and cocodamol was administered. C was categorised as a priority level 3 for urgent but stable conditions, which should be seen within one hour. C was advised that they may have to wait seven hours as the A&E was busy. C left the A&E as they felt too unwell to wait. They were returned to hospital the following evening, by ambulance, with sepsis and blood clots in their lungs.

The board advised that C was correctly prioritised according to the observations and symptoms recorded at the time. They advised that a nurse in charge would check patients during their waiting time and re-categorise as necessary. They also advised that more detailed checks and tests would be done at the point of medical assessment. We found that the triage process was in line with guidance and that the categorisation was correct. However, we noted that the blood pressure reading was high and should have been rechecked. We also noted that the extended waiting time for triage and medical assessment was not in line with guidance.

On careful balance, we found that the triage process was reasonable because C was correctly categorised. We acknowledged that if C had waited, further review and medical assessment would have taken place. We did not uphold the complaint.

Summary

C complained on behalf of their child (A) who was a patient of the practice. A's care was disrupted by COVID-19 and they were not seen by the practice for four years. C complained that the practice unreasonably charged them for white fillings after there was a delay in A being seen for routine check ups and the care could have been provided at a time when it would have been free of charge. C also complained that the practice failed to reasonably respond to C's complaint.

We took independent advice from dental adviser. We found that the decision to charge for the care and treatment provided was reasonable. It was not possible to evidence whether appointments had been sought prior to their appointment, and the decision to charge for the treatment provided was reasonable. Therefore the complaint was not upheld.

We found that while the content of the practice's complaint response was reasonable, there were significant delays in the practice providing a response and there were a number of times when C requested to escalate their complaint and this was not actioned, which we found unreasonable. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in responding to the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available HYPERLINK "http://www.spso.org.uk/meaningful-apologies" http://www.spso.org.uk/meaningful-apologies .

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

C complained about the care and treatment provided by nursing staff to their late sibling (A), who was admitted to hospital with a chest infection. A was discharged with injuries and delirium, which C believed was due to a fall they had shortly after admission. A was a wheelchair user and especially vulnerable to falls because of their bone condition (osteoporosis). C said that a full assessment of A’s risk of falling was not carried out and that the fall caused A to deteriorate, and led to their death three months later.

We took independent advice from a registered nurse adviser. We found that the standard of nursing care provided was not reasonable in that a falls risk assessment was not carried out fully and accurately, documentation and record keeping did not meet the required standards, communication needs were not met and full learning and improvement was not achieved because a significant adverse event review was not carried out. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of nursing care and treatment and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients who are at risk of falling should have a full falls risk assessment and all appropriate interventions to reduce the risks as much as possible. Families/carers should be informed of a patient’s fall within a reasonable time. Documentation and recordkeeping should meet the required standards. Adverse event reviews should be carried out in line with the relevant framework.

In relation to complaints handling, we recommended:

• Complaints should be investigated fairly and fully and in line with the requirements of the NHS model complaints handling procedures. Complaint responses should be accurate, complete and address all the points raised in line with the NHS model complaints handling procedure. We offer SPSO accreditedComplaints Handling training. Details and registration forms for our onlineself-guided Good Complaints Handling course (Stage 1) and our onlinetrainer-led Complaints Investigation Skills course (Stage 2) are available athttps://www.spso.org.uk/training-courses.

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.