Health

Summary

Ms C, who works for an advice and support agency, complained on behalf of her client (Mr A) about the care and treatment provided to him at Uist and Barra Hospital. Mr A was catheterised (a process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection), and Ms C complained that this was done unnecessarily, and without his consent. She also complained that the record-keeping for this admission was not of an appropriate standard.

We took independent advice from a consultant physician and a nurse. We found that it had been necessary from a medical standpoint to catheterise Mr A. We also found that whilst Mr A's consent was not documented, there is no requirement for this and there was no evidence to suggest that Mr A did not consent to catheterisation. We considered that record-keeping was of a reasonable standard. We did not uphold these aspects of Ms C's complaint.

Ms C also complained that Mr A's initial verbal complaints were not handled appropriately. The board accepted that this was the case and we, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to handle his initial verbal complaints appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Verbal complaints should be handled in line with the complaints handling procedure.

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

Mr C complained on behalf of his late wife (Mrs A) that an ambulance crew unreasonably failed to take Mrs A to hospital. Mrs A had taken a reaction to medication which had recently been prescribed for her and her blood pressure had dropped to a dangerous level. The crew felt that it was appropriate for Mrs  A to remain at home as she was due to have a visit from a specialist nurse the following day. Mrs A died a short time later.

We took independent advice from a professional adviser. We found that the crew had managed to obtain two blood pressure readings from Mrs A and they were both at critically low levels. We considered that the blood pressure readings should have indicated that Mrs A was critically unwell and required assessment and treatment at the hospital which may have prevented her death. Therefore, we upheld Mr C's complaint.

We did not make any recommendations in this case as the ambulance service have accepted these failings, apologised and taken appropriate actions to prevent future failings.

Summary

Ms C complained that NHS 24 failed to provide appropriate assistance when she called them to raise concerns that her mother (Mrs A) had been discharged from hospital too early following a suicide attempt. She said that she had not received any advice or assistance and complained that she had only been able to speak to a call handler and not a clinician.

We took independent advice from a practitioner experienced in out-of-hours services. We found that NHS 24's handling of the call had been reasonable. The call handler contacted Mrs A, who had told them that she had been seen by psychiatry that day and had psychiatric follow-up arranged. The call handler also spoke to a senior nurse. We found that the advice provided to Ms C had been appropriate and it had been reasonable to advise her to contact Mrs A's GP practice at that time. We did not uphold the complaint.

Ms C also complained about NHS 24's handling of her complaint. We found that this had been reasonable and did not uphold this aspect of the complaint.

Summary

Mr C complained about the treatment which he received when he attended the Western General Hospital for reported left upper abdomen pain. He said he had advised staff that he was allergic to aspirin and penicillin but was prescribed diclofenac medication (pain relief) on discharge. When he returned home, Mr C took two further diclofenac tablets and experienced breathing difficulties. He attended his GP the following day who prescribed alternative pain relief. Given his allergies, he felt that the diclofenac should not have been prescribed.

We took independent medical advice from a consultant. We found that although diclofenac would not normally be prescribed for a patient allergic to aspirin it was not absolutely contraindicated and should be used with caution. We also found that diclofenac was a non-steroidal anti-inflammatory medication (NSAID) and Mr  C had advised the staff that he was able to tolerate some NSAIDs. We noted that Mr C had been given diclofenac whilst in hospital and that it had a good effect on his reported abdomen pain and he was given advice to seek further medical attention should his condition deteriorate following discharge. On balance, we found that it was reasonable for the doctor to have prescribed the diclofenac. We did not uphold Mr C's complaint.

Summary

Mr C complained about the lack of treatment which he received at St John's hospital. He had been referred to the mental health service by his GP for an assessment. Mr C complained that the board failed to carry out appropriate mental health assessments. He was also dissatisfied that the board would not arrange a further medical opinion.

We took independent advice from a consultant psychiatrist (a specialist in the diagnoses and treatment of mental illness). We found that Mr C was seen on two occasions by a doctor in training who discussed Mr C with a supervising consultant psychiatrist. There was evidence that thorough assessments were carried out on both occasions which resulted in a reasonable management plan. Mr C was then assessed by another consultant psychiatrist, who again carried out an appropriate assessment in view of Mr C's reported symptoms. The clinicians reasonably concluded that Mr C was not suffering from a diagnosable mental health disorder. We considered the assessments to be reasonable and did not uphold this aspect of Mr C's complaint.

In relation to a further medical opinion, we noted that Mr C had been assessed twice by a trainee doctor, under supervision of a consultant psychiatrist, and also by an additional consultant psychiatrist. Therefore, we found that it was not unreasonable that the board did not offer Mr C a further medical opinion. We did not uphold this aspect of Mr C's complaint.

Summary

Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C also complained about the personal care that Mrs A received and the communication from nursing staff.

We took independent advice from a nursing adviser. We found that:

• the number of ward moves that Mrs A experienced was unreasonable in view of her reduced cognitive function and delirium (sudden confusion)

• the board had failed to keep adequate records regarding the risk assessment and decision making for Mrs A's ward moves and how Mrs A and her family were informed of the ward moves

• the board failed to adequately assess and document Mrs A's care needs. In particular there was no care plan in place to cover Mrs A's personal hygiene needs

• a “Getting to Know Me” document was not in use during Mrs A's admission to St John's Hospital.

In light of the above we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the number of ward moves that Mrs A experienced, the failure to keep adequate records regarding Mrs A's ward moves, the failure to adequately assess and document Mrs A's care needs and complete a 'Getting to Know Me' document. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The movement of patients with cognitive impairment between wards should be in line with national standards and guidance.
• The reason for moving patients to another bed, room or ward should be clearly documented and shared with the patient and/or their representative in accordance with Standard 15 of the Care of Older People in Hospital Standards.
• Nursing assessments and care plan documentation should clearly document the care needs and preferences of patients.
• The 'Getting to Know Me' document should be completed and used to inform a person-centred care plan.

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

Mr C complained on behalf of his friend (Mrs A) about the care and treatment she received at the Western General Hospital. Mrs A was referred to neurosurgery (the branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) and was found to have signs of wear and tear to the discs in her cervical spine (the soft cushions of tissue between the vertebra), which was causing compression (squeezing) to her spinal cord. A scan showed that this had caused mature damage in one area of her spinal cord.

Mrs A was referred for surgery to prevent her condition from worsening. Specifically, an anterior cervical discectomy and fusion (where disc material is removed to reduce spinal cord compression). After her surgery, Mrs A experienced weakness and reduced mobility. The board carried out a further scan, which found that Mrs A had mature damage in a second area of her spinal cord. Mr C complained that the surgery went wrong and that Mrs A was never told that surgery could make her condition worse.

We took independent medical advice from a consultant neurosurgeon. We found that Mrs A was appropriately referred for surgery, as she had signs and symptoms of spinal cord compression. However, we found that there was insufficient evidence that the risks of surgery, and of not having surgery, were clearly explained to Mrs A in the consent process. We also found that as Mrs A signed the consent form on the morning of the surgery, she was not given a reasonable timeframe to consider the risks listed on it.

We considered that the surgery might have caused Mrs A's new mature spinal cord damage, given the steps involved. However, we also found there were signs that Mrs A's spinal cord compression had worsened in the months before her surgery. Therefore, we were unable to definitely conclude that the surgery had caused her new mature spinal cord damage. Nevertheless, we found that the possibility of this happening and the other risks involved, should have been appropriately explained to Mrs A and documented. In light of that failing, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings identified in the surgical consent process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery, and what is discussed as part of the consent process (including risks and benefits) should be documented.

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

Mrs C complained to us about the nursing care and treatment her mother (Mrs A) had received at the Western General Hospital after she had fallen and injured her head. Mrs C, who had power of attorney for Mrs A, was concerned about the nursing care she received. Mrs C had particular concerns about her falls care and monitoring; pain relief; personal care and hygiene; and the communication with Mrs A. Mrs C also had concerns about a lack of response to Mrs A's weight loss and to her swollen leg.

We took independent advice from a nurse. We found that there was a failure to prepare timely and comprehensive care plans in relation to Mrs C's care needs, and to review the ongoing effectiveness of those care plans. We found that this should have been carried out with the appropriate involvement of Mrs C and her powers of attorney but there was no evidence that this had been done. We also found that there were failings in the board's records-keeping, as there were gaps in completing care round checklists which were sometimes not completed fully. We upheld Mrs C's complaint.

We noted that the board did not identify the failings we found in the nursing care provided to Mrs C. In addition, the board did not provide us with all relevant documentation at the appropriate point in our investigation. Therefore, we made recommendations in relation to their complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in the nursing care Mrs A received.

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

• Patients should have comprehensive nursing assessments and clear care plans in place, which are regularly reviewed, to facilitate consistent and person-centred care, with the appropriate involvement of patients and their powers of attorney.
• Care round checklists should be completed consistently and fully.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.
• The board should ensure that clinical evidence demonstrating the treatment and care provided is provided at the appropriate point in an SPSO investigation.

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

Ms C complained about matters related to the care and treatment of her son (Mr  A), who had been an in-patient at the Royal Edinburgh Hospital. Mr A had a diagnosis of schizophrenia (a long term mental health condition that causes a range of different psychological symptoms) and had been subject to a Compulsory Treatment Order (an order that allows professionals to treat a person's mental illness). During the in-patient admission, the local authority's social work staff were working towards finding a suitable supported accommodation vacancy for Mr A, with input from clinicians. Ms C firstly raised concerns that board staff had contributed to delays in progressing Mr A towards discharge. We received independent advice from a consultant psychiatrist. We found that the clinical team reasonably fulfilled their responsibilities to identify a suitable accommodation placement for Mr A. We did not uphold this complaint.

On a particular occasion during the admission, Mr A did not return to the hospital following an agreed one hour period of leave. The hospital notified the police the next morning and informed Ms C later that day. Ms C raised concerns that the board failed to apply the correct risk level to Mr A's absence. We did not find evidence that the board had acted in accordance with the procedure for missing persons that was in use at the time. We upheld this complaint, however, we noted that the board had since revised and improved this procedure.

We also noted that the board's complaint investigation referred to the relevant procedure but did not identify that staff had not complied with this. We were critical of the complaint investigation and made a recommendation in relation to this.

Ms C was also unhappy with the level of communication with her during the time Mr A was absent from the hospital. In response to her complaint, the board acknowledged that there had been a delay in contacting Ms C to notify her. We found limited documentation of communication with Ms C and we concluded that communication was not in line with the procedure in place at the time. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mr A for the failure to follow their Standard Operating Procedure for Missing Persons. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be familiar with the procedures to follow when a patient goes missing, and confident in applying these correctly.
• When a detained patient is missing, factual details such as dates/times of significant events and information discussed with next of kin and police should be recorded.

In relation to complaints handling, we recommended:

• A complaint investigation should identify any applicable policies or procedures and assess whether these have been followed (and if not, why).

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

Ms C complained about a number of aspects of the mental health care and treatment provided to her by the board over a number of years. In particular, Ms  C felt that the board failed to provide her with appropriate crisis support and appropriate psychiatric treatment. Ms C also complained that their communication around these matters was unreasonable and that their handling of her complaint was poor.

We took independent advice from a mental health nurse and a psychiatrist. We found that some of the crisis care provided to Ms C was reasonable, however, there were a number of areas where care could have been improved. We were not satisfied that the board had taken appropriate action, following an upheld complaint about staff attitude, to ensure that this issue did not impact on Ms C's access to the service in future. The mental health adviser noted that an out-of-hours care plan was not reviewed within the appropriate scheduled timescale and that the board held conflicting information in relation to Ms C's ability to access other services. Therefore, we upheld this aspect of Ms C's complaint.

In relation to Ms C's psychiatric treatment, we found that the care provided by a psychiatrist and a psychologist was reasonable. The psychiatric adviser noted that both the psychological treatment that Ms C received, and the administration of medication, was appropriate. Therefore, we did not uphold this aspect of Ms  C's complaint.

Additionally, Ms C felt that the board's communication around these matters had been poor as she had been unreasonably excluded from meetings where her care was being discussed. The psychiatric adviser considered that the board followed their usual and appropriate practice in relation to meetings held about a patient. We did not find evidence to suggest that Ms C had been unreasonably excluded from these meetings and that the boards communication with her was unreasonable. Therefore, we did not uphold this aspect of Ms C's complaint.

Finally, we found that the board had not consistently handled Ms C's complaints in line with their complaint handling guidance in place at the time. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that since Ms C first made a complaint, a new complaints handling procedure has been introduced by the board and therefore, we made no recommendations for improvement on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to review her out-of-hours care plan as had been scheduled, failing to communicate with her consistently and accurately about her ability to access a crisis support service and failing to handle her complaints appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should treat patients with courtesy and respect at all times. Staff should have access to appropriate focused clinical support and supervision.
• Care plans should be reviewed within the scheduled timescale. Where this is not possible, a reason for this should be documented. Care plans should accurately reflect a patient's ability or inability to access other support services, and communication about this matter should be consistent.

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.