Health

Summary

C complained on behalf of their client (B) about the care and treatment given to B's late parent (A). A was admitted to hospital and discharged a few days later. A was readmitted the next day and died the following week. B had concerns around A's diagnosis and said that they should have been consulted given that they held Welfare Power of Attorney (Welfare POA). C also complained that the board's communication with B was unreasonable.

The board said that A was treated for infection with broad spectrum antibiotics. A was discharged after their first admission as it was deemed appropriate and clinically safe to do. The board said that during A’s second admission a lumbar puncture procedure was indicated. They acknowledged that an Adults with Incapacity (AWI) certificate was in place and that during that time, Welfare POA rights were in effect. However, the board said that when the AWI certificate was revoked, the Welfare POA did not maintain the ability to make decisions on the patient’s behalf.

In relation to communication, the board apologised that B found the manner of staff to be abrupt and explained that the situation was urgent.

We took independent advice from a consultant physician in medicine for the elderly. We found that A received appropriate care and treatment. Appropriate investigations were carried out and various diagnoses were considered during A’s treatment. However, the board did not seek appropriate informed consent from B for a medical procedure when the AWI certificate was in place which was unreasonable.

We found that the content of the communication recorded in the medical notes was reasonable. However, the tone of communication lacked sensitivity and respect of B and their role as the Welfare POA. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to appropriately discuss treatment plans and seek their consent as the power of attorney for an incapacitated patient, communicating with B in an inappropriate way, failing to address all of the concerns raised in their complaint response, and failing to provide full and detailed responses and explanations in their response to the complaint.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:

• Detailing planned treatments on patients with an AWI certificate in place should be done with the full involvement of the power of attorney holder (or equivalent). When an AWI certificate is in place, consent for procedures should be sought from the power of attorney holder (or equivalent) before procedures are carried out.
• When communicating with patients, their families, and/or their power of attorney holders, the board should ensure that the content of the communication is accurate, whilst also paying mind to the manner in which they are communicating. Care should be taken to communicate in a way that is sensitive to the circumstances, compassionate, and respectful.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in line with the NHS Model Complaints Handling Procedure. When specific issues have been raised, these should be fully investigated and a meaningful response provided including, where appropriate, an explanation of the board’s position and the reasons why action was taken, rather than simply stating the facts of the situation. When a complaint investigation indicates that an apology is appropriate these should, insofar as possible, be sincere and acknowledge the impact on the complainant whilst meeting the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. 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.

Summary

C complained that the practice failed to adequately investigate and/or diagnose the cause of their persistent cough. C was subsequently hospitalised and diagnosed with pneumonia while on holiday.

The practice did not uphold C’s complaint. They said that they had taken reasonable action in light of C’s presenting symptoms and that C’s cough had been reasonably treated. They said that C’s final examination was normal and not in keeping with a diagnosis of pneumonia and that, therefore, there was no missed diagnosis.

C remained unhappy and asked us to investigate. We took independent advice from a GP. We found that there had been a failure to adequately investigate the cause of C’s cough. In light of C’s presenting symptoms, a persistent cough and infection, we found that an in person appointment and an urgent referral for a chest x-ray should have been considered after their initial telephone presentation. We also considered that C should have been referred for an urgent chest x-ray following a second presentation, in accordance with the Scottish Referral Guidelines for Suspected Cancer. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately investigate the cause of their persistent cough. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patient treatment should be considered in line with relevant guidance.

Summary

C had a bilateral total knee replacement surgery, which was carried out by another organisation. Approximately three weeks after their surgery, C was admitted to a hospital within Forth Valley NHS Board following a fall. Approximately three weeks after C’s discharge, C had surgery to repair a tendon in their right quadriceps (thigh muscle), which was carried out by another organisation.

C complained about the care and treatment that they received in hospital during their admission and the care and treatment that they received from the outpatient physiotherapy service over the next six months.

The board said that the presentation of C during their hospital admission was a common presentation following knee replacement surgery and very similar to the presentation for an injury to the quadriceps. The board said that the outpatient physiotherapy guidance was followed when treating C.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a physiotherapist.

We found that the board failed to consider a right-sided quadriceps tendon injury when C was seen by a consultant in hospital, failed to reassess C during their admission and failed to escalate C when C did not progress when in hospital. On this basis, we upheld this part of C’s complaint.

In relation to the physiotherapy service, we found that the exercises C received were in line with post-operative guidance and that physiotherapists followed protocols for treating C. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified by this investigation. 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 Morbidity and Mortality meeting scheduled should include input from physiotherapy; discuss appropriate escalation procedures, including who to contact if a consultant is unavailable; and how patients are reviewed as inpatients, with a view to reviewing patients daily.

Summary

C complained about the medical care provided to their late parent (A) by the board when they were admitted to hospital. We took independent advice from a consultant in emergency medicine. We found that there should have been better communication between the medical, nursing, and other allied health professional staff in relation to bruising found on A. We found that medical staff failed to take note of the physiotherapy findings of bruising and to document the presence of any significant injury.

We also found that medical staff should have prescribed a second antibiotic at the time of A’s admission, that an assessment using arterial blood gas analysis should have been carried out before A’s transfer to the critical care unit and that the mental health team failed to assess A’s delirium, or prompt medical staff to consider this. Finally, we noted that the cause(s) of A’s death should have been recorded in more detail on the death certificate. Therefore, we upheld this part of C's complaint.

C also complained about the nursing care that the board provided to A. We took independent advice from a nurse. We found that nursing records, in particular, risk assessment and care planning documents, were not always completed to the required standard or frequency. We also found that A did not receive a reasonable standard of person centred care in relation to their fluid intake and nutritional support and there was poor and inadequate support provided to assist A with their personal hygiene. Nursing staff should also have identified earlier the bruising on A’s body and ensure A had timely access to their medications.Therefore, we upheld this part of C's complaint.

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/information-leaflets.

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

• A patient’s cause of death should be accurately recorded.
• All relevant staff should be aware of the board’s responsibilities under the Adults with Incapacity (Scotland) Act 2000.
• All relevant medical staff should have read and understood the contents of the board's doctors handbook.
• Arterial blood gas analysis should be considered for 'any patient with a new oxygen requirement' and 'all critically ill patients'.
• Patients should receive their prescribed medication at the appropriate time.
• Patients should be appropriately examined and assessed and findings from the examination / assessment should be appropriately recorded and communicated.
• Patients should be appropriately examined and assessed. Relevant documentation should meet the standard required by the NMC The Code. All nursing staff involved in this case should be aware of their requirements to document to the standard required by the board and the NMC to ensure patient safety, person centred care and essential communication.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the relevant model complaint handling procedure. 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.

Summary

C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died.

We took independent advice from a nursing adviser and consultant geriatrician (specialist in medicine of the elderly). In relation to nursing care, we found failings with A's nutrition, pressure care, person centred care planning, and documentation. We upheld this part of C's complaint.

In relation to medical care and treatment, we generally found this to have been reasonable and did not uphold this part of C’s complaint. However, we provided feedback to the board regarding starting oral nutrition supplements in line with Scottish Hip Fracture Guidance.

Finally, we found that there were delays in the handling of C's complaint and the board failed to fully address of all C's concerns. The board had acknowledged these failings and taken action to address them. Therefore, we upheld this part of C's complaint but made no further recommendations in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in nursing care provided to A, and the failings in 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:

• Appropriate assessments should be accurately completed in a timely manner to identify patients at risk of or with existing pressure sore damage. Those patients should receive appropriate and timely pressure sore care in accordance with relevant local and national guidance.
• Malnutrition Screening should be completed in a timely manner and repeated as appropriate. Food charts should be completed accurately.
• Person-centred care planning should be completed for every patient, and documentation should support this.

Summary

C complained about the care and treatment they received from the board when they attended the hospital with pain and a tight feeling in their leg. C raised concerns that the board failed to: reasonably assess them on admission to hospital, and undertake the correct scans; provide them with timely information about their test results; reasonably identify an arterial clot and diagnose their condition; and provide them with reasonable treatment following admission to hospital.

We took independent advice from a consultant in acute medicine. We found that a detailed clinical assessment of C’s right leg and foot was carried out on their admission to hospital, and that it was reasonable that the clinicians did not identify an arterial clot at that time. We found that the possible diagnoses that were considered at the time were correct, and the diagnosis of plantar fasciitis was a reasonable conclusion to have reached. We also found that the correct scan had been carried out to exclude deep vein thrombosis (DVT, a blood clot in a vein) as a cause of C’s symptoms, and that the care and attention C received from medical staff was reasonable.

Therefore, we did not uphold C’s complaint.

Summary

C complained about the medical and nursing care they received for a spinal condition. C said the care led to avoidable complications and delayed their transfer to a specialist spinal unit.

We took independent advice from a consultant in orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found a number of failings in the nursing care C received. This included poor record keeping and a failure to manage C’s skin care appropriately. This led to avoidable pressure injuries which were a significant factor in delaying C’s transfer. In terms of medical care, we found that the ward C was placed on lacked the necessary equipment to manage a patient in their condition. We found the medical and nursing care C received fell below a reasonable standard and upheld these parts of C’s complaint.

C also complained that the board failed to provide them with a reasonable standard of physiotherapy. We found that C’s physiotherapy care was of a reasonable standard and was well documented, showing regular review up to the point physiotherapy was stopped on medical advice. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with a reasonable standard of medical and nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Wound charts should be in place for pressure wounds and there should be subsequent weekly assessments. Care rounding should be delivered to the frequency required to prevent pressure damage. Patients should be appropriately moved position to avoid worsening pressure damage.
• Nursing staff correctly follow CPR for feet guidelines and develop person centred treatment plan for patient foot care.
• Patients should be transferred to a hospital and ward which can provide the care they need.
• That a duty of candour review is considered in light of the SPSO's findings.
• When a relevant adverse event occurs, the board should complete a SAER.

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 on behalf of their client (B) that the care and treatment provided to B's relative (A) was unreasonable.  

In response to the complaint, the board acknowledged that there had been failings in the delivery of care throughout A’s hospital stay and explained that action had been taken in response to these failings.

We took independent advice from a nurse. We found areas of good practice. However, we found significant and serious failings in A’s care in relation to delirium, observations and vital monitoring, record-keeping and escalation processes. Therefore, we upheld C’s complaint. We recognise the learning implemented by the board which has led to significant learning and improvements to patient care and has addressed the failings identified in this case. 

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

We also provided feedback that the board should reflect on the advice we received that the score given on the serious adverse event review (SAER) report was not reflective of the failures identified in this case. We also noted that a SAER should be reviewed in a timely manner in partnership with the patient and/or their family/carers and that in this case, A's family should have received regular updates. 
 

Recommendations

In relation to complaints handling, we recommended:

• Complainants should be kept updated on their complaints in line with the Model Complaints Handling Procedure. 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.

Note - 30 May 2025

On 21 May 2025, an earlier version of this summary was published in place of the intended final version due to an administrative error. This has now been corrected. We apologise for any confusion this may have caused.

Summary

C complained about being de-registered from their dental practice. C also complained that the practice failed to handle their complaint reasonably. Due to a broken tooth, C phoned for an emergency appointment and was told they could attend the same day. However when C arrived, they were given a temporary substance to place over the tooth until an appointment the next day. When C later phoned the practice to explain their situation had worsened, they were told to wait until the following day. C emailed the practice to complain about the service they had received but returned the following day to have the tooth treated. A year later, C requested an emergency appointment but was told that they had been de-registered and would not be seen.

We found that there was only very limited evidence to show that the de-registration letter was ever sent and that there was a delay in doing so. We found that the lack of record keeping in this case has made it difficult to assess the practice’s complaint handling. This in itself is unreasonable, given the concerns C raised. Overall, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be notified of de-registration from the practice within a reasonable timeframe. Letters sent by post should be correctly addressed.

In relation to complaints handling, we recommended:

• All complaints should be handled in line with the NHS Model Complaints Handling Procedure (MCHP). In particular, where an early resolution response is provided, a full and accurate record of the decision reached and given to the person should be made. 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 board’s decision not to provide thyroid chondroplasty (a surgery to reduce the size of the Adam’s apple) as part of their gender affirming treatment. The board explained that though they used to have surgeons who could carry out this surgery, they no longer do. They said that the Scottish Government does not fund thyroid chondroplasty and therefore they cannot recruit surgeons for the purpose of performing the surgery and are prevented from using public finances to fund it.

We found that there is no obligation for the board to provide thyroid chondroplasty on the basis of Scottish Government protocols. However, protocols state that health boards should ensure they have clear documentation on what is available to their patients and have local policies in place regarding access to them. We gave feedback to the board on this point, but ultimately did not uphold C’s complaint.

C also complained that when they were in the process of having hair removal prior to gender reassignment surgery, the board stopped providing this service. Because hair removal at the site of surgery is a requirement, C had to pay for the hair removal to be completed privately.

During the course of our investigation, the board accepted that they had not been clear to them at the point of C’s complaint that it is the responsibility of the health board where the patient lives to arrange hair removal prior to gender reassignment surgery. The board apologised for the failure and financial inconvenience caused and offered to reimburse C for the laser hair removal. We upheld the complaint and made no further recommendations.